Emergency Physician Perceptions of Medically Unnecessary Advanced Diagnostic Imaging

Abstract

Objectives: The objective was to determine emergency physician (EP) perceptions regarding 1) the extent to which they order medically unnecessary advanced diagnostic imaging, 2) factors that contribute to this behavior, and 3) proposed solutions for curbing this practice.Methods: As part of a larger study to engage physicians in the delivery of high-value health care, two multispecialty focus groups were conducted to explore the topic of decision-making around resource utilization, after which qualitative analysis was used to generate survey questions. The survey was extensively pilot-tested and refined for emergency medicine (EM) to focus on advanced diagnostic imaging (i.e., computed tomography [CT] or magnetic resonance imaging [MRI]). The survey was then administered to a national, purposive sample of EPs and EM trainees. Simple descriptive statistics to summarize physician responses are presented.Results: In this study, 478 EPs were approached, of whom 435 (91%) completed the survey; 68% of respondents were board-certified, and roughly half worked in academic emergency departments (EDs). Over 85% of respondents believe too many diagnostic tests are ordered in their own EDs, and 97% said at least some (mean = 22%) of the advanced imaging studies they personally order are medically unnecessary. The main perceived contributors were fear of missing a low-probability diagnosis and fear of litigation. Solutions most commonly felt to be "extremely" or "very" helpful for reducing unnecessary imaging included malpractice reform (79%), increased patient involvement through education (70%) and shared decision-making (56%), feedback to physicians on test-ordering metrics (55%), and improved education of physicians on diagnostic testing (50%). Conclusions:Overordering of advanced imaging may be a systemic problem, as many EPs believe a substantial proportion of such studies, including some they personally order, are medically unnecessary. Respondents cited multiple complex factors with several potential high-yield solutions that must be addressed simultaneously to curb overimaging.ACADEMIC EMERGENCY MEDICINE 2015;22:390-398

Emergency Physician Perceptions of Shared Decision‐making

“…20 While several studies have suggested that SDM may lower health care costs and usage, 4,5,7,8 others have questioned its ability to do so. 25 In either case, we believe that it would be inappropriate to promote SDM predominantly as a cost-saving measure, as the primary goal of SDM relates to its role in supporting the ethical obligation of physicians to ensure that patients have the opportunity to choose the care that is most suitable for them, when a reasonable choice exists.…”

“…20 Briefly, this was a cross-sectional survey approved by our institutional review board. The final survey was administered to a nationally distributed, purposive sample of EPs recruited at four EM conferences (including Society for Academic Emergency Medicine and continuing medical education conferences) and 15 distinct ED group meetings.…”

CJEM Debate Series: #Copayment – Medical insurance is for non-routine events

“…Indeed, physicians are far more likely to order interventions that financially benefit them personally, [13][14][15][16][17] and acknowledge sometimes ordering medically unnecessary tests and treatments, because of malpractice concerns or the fear of being blamed if something goes wrong. 18,19 Cost-sharing is also patently unjust, as it hits hardest the pocketbooks of the poor and older adults. Although truly substantial cost-sharing would likely deter most everyone other than the very wealthy, this would be politically unfeasible; relatively limited cost-sharing, on the other hand, can be expected to primarily deter the poor, and older adults on a fixed income, from accessing health care.…”

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“…The frequency of head CT varies, as does the performance and resultant radiation dose estimations across ages [26][27][28][29]. In addition, there is variability in adherence to best practice clinical guidelines [30][31][32][33][34]. The issue of head CT and cancer risk is debated [35][36][37][38][39][40][41]; parental as well as emergency department providers' understanding of medical radiation exposure and cancer risk can vary [42][43][44][45].…”