The costs and utility of imaging in evaluating dizzy patients in the emergency room

Abstract

Objectives/Hypothesis: To determine the usefulness and the costs of computed tomography (CT) and magnetic resonance imaging (MRI) in the evaluation of patients with dizziness in the emergency department (ED).Study Design: Retrospective chart review. Methods: Charts of patients with a specific health maintenance insurance plan presenting with dizziness and vertigo to a large health system's ED between January 2008 and January 2011 were reviewed. Patient demographics, signs/symptoms, and CT and MRI results were assessed. CT and MRI charges were determined based on positive versus unremarkable findings. Data analysis included stepwise logistic regressions.Results: Of 1681 patients identified, 810 (48%) received CT brain/head scan totaling $988,200 in charges. Of these, only 0.74% yielded clinically significant pathology requiring intervention. However, 12.2% of MRI studies yielded discovery of significant abnormalities. Logistic regression analysis revealed that older patients (P ¼ .001) were more likely to receive a CT scan.Conclusions: In the 3-year period studied, CT scans for ED patients with dizziness and vertigo yielded a low predictive value for significant pathology. These data reveal a great opportunity for cost savings by developing stricter guidelines for ordering CT scans for this set of ED patients. The use of MRI in all cases of dizziness was found to be neither practical nor useful. However, appropriately directed MRI of the brain is recommended in patients with dizziness and other neurological signs or symptoms.

Dizziness in a community hospital: central neurological causes, clinical predictors, and diagnostic yield and cost of neuroimaging studies

“…Recent studies have reported that brain imaging scans are ordered in 27–48% of visits by patients with dizziness, yielding diagnoses in 0.74–7% of patients [23,24,27]. The literature consistently shows that physicians order more CT brain scans than MRI scans in dizziness evaluations despite the known fact that MRI brain scans exhibit better sensitivity in diagnosing stroke (83% versus 26%), especially in posterior circulation stroke, which is usually the concern in these cases [28,29].…”

Benign Paroxysmal Positional Vertigo in the Acute Care Setting

“…72 Indeed, the increasing cost of emergency department management of dizziness seems to stem from both an increase in the presentation of dizziness and to the increasing use of imaging studies. 73,74 The last decade has shown that patients with vertebrobasilar stroke may present with isolated vertigo and the differentiation between a central and a peripheral cause of vertigo in the emergency department is of paramount importance. In a prospective study of 100 consecutive patients with positional nystagmus, the vast majority (80%) had BPPV and only 12% clearly had a central vestibular disorder.…”

TiTrATE

“…90, 118 Routine MRI in all ED dizziness also has a low yield. 21 Imaging only older patients with vascular risk factors is a common practice, but the countervailing concern is that young age predisposes to missed stroke. 13, 119, 120 Stroke risk in patients presenting isolated s-AVS and no vascular risk factors is still roughly 10–20%, and one in four strokes occurs in a patient under age 50.…”

“…On average, however, diagnosing dizziness consumes disproportionate resources through extensive testing and hospital admission. 1, 4 Indiscriminate application of CT, CTA, and MRI has low yield and low value in this patient population, 17–21 yet brain imaging for dizziness continues to increase steadily over time. 4 Use of brain imaging varies 1.5-fold across hospitals without differences in the detection of neurologic causes.…”