4 key takeaways from a new study on imaging utilization in the ED

Patients in the United States are depending on the emergency department (ED) for care more and more, a trend that has had a significant impact on imaging utilization.

The authors of a new study in the American Journal of Roentgenology analyzed this topic in great detail, exploring public Medicare data from 2004 to 2016 and Health Care Cost and Utilization Project data from 2006 to 2014. These are four key takeaways from that team’s findings:

1. Imaging utilization in the ED is on the rise

Imaging utilization in the ED has increased among Medicare beneficiaries by a whopping 38.4%, moving from 14.6 million exams in 2006 to 20.2 million in 2014. In addition, the number of examinations per ED visit for that same patient population is up from 0.73 in 2006 to 0.94 in 2014.

“The key finding from our data is that the volume of imaging in EDs in the United States is not only increasing in the Medicare fee-for-service population but also increasing per ED visit,” wrote Santosh Kumar Selvarajan, MD, department of radiology at Thomas Jefferson University Hospital and Sidney Kimmel Medical College in Philadelphia, and colleagues. “To our knowledge, no study of ED imaging has addressed this relationship.”

2. CT utilization in the ED is up big

CT utilization in the ED among Medicare patients is up 153% from 2004 to 2016. Noncardiac ultrasound (134%), x-rays (30%) also saw significant gains. The authors noted that the gains for CT imaging come after code bundling in 2011.

“The possible reasons for increased use of CT include technologic advances, the utility of CT in accurate diagnosis of multiple ED problems, the availability of 24-hour CT coverage in many EDs, lack of a preauthorization requirement for CT in the ED in the United States, fear of malpractice liability, increased demand for rapid turnover in the ED, and availability of overnight coverage by radiologists,” Selvarajan and colleagues wrote. “However, this increased use of CT in the ED has not altered the overall rate of hospital admissions.”

3. Radiologists interpreted a wide majority of ED imaging examinations for Medicare beneficiaries

Radiologists interpreted 99.5% of CT examinations in the ED in 2016, with a mix of emergency physicians, radiation oncologists, neurologists and primary care providers interpreting the other 0.5%. Radiologists also interpreted 99.2% of MRI examinations, 98% of x-ray examinations, 87.6% of ultrasound examinations and 94.5% of nuclear medicine examinations among Medicare beneficiaries.

4. Overutilization is a concern, and attempts are being made to address it

Overutilization in the ED is an issue researchers and advocates have been tracking for quite some time, working to find potential solutions to this growing trend.

“Various initiatives have been undertaken to try to limit the use of imaging to only circumstances in which it is appropriate,” the authors wrote. “The initiatives include use of the Canadian clinical rules, development of the extensive American College of Radiology Appropriateness Criteria, and launching of the Choosing Wisely campaign by the American Board of Internal Medicine Foundation.”

So why haven’t these actions had a bigger impact? One theory suggested by the authors is that ordering physicians in the ED are either unaware of them altogether, or are ignoring them.

“It therefore behooves all radiologists to work more closely with their ED colleagues to provide education on the importance of appropriate use,” Selvarajan and colleagues added.