June 27, 2019

Study finds reducing over-testing in Emergency Departments could save millions


A new study developed with the assistance of Wayne State University School of Medicine faculty finds there’s excessive imaging testing being performed in emergency departments. A reduction could save millions in health care costs.

An emergency department is sometimes the first place a person thinks to go for health care.

“The emergency department is an essential care setting, treating over 145 million annual visits in the United States across a wide range of patient populations, from children to adults,” said Keith Kocher, M.D., M.P.H., assistant professor of Emergency Medicine at Michigan Medicine. “This translates to about $3.8 million annually in avoidable spending on low-value care.”

It’s for this very reason that Michele Nypaver, M.D., a professor of Emergency Medicine and Pediatrics at Michigan Medicine and University of Michigan C.S. Mott Children’s Hospital, said the emergency department setting represents the ideal venue to implement practice improvement efforts to ensure high-quality care, informed by the best available evidence.

Drs. Kocher and Nypaver are the program directors of the Michigan Emergency Department Improvement Collaborative, or MEDIC, a physician-led statewide quality network connecting a diverse set of unaffiliated emergency departments with the goal of improving quality and reducing low-value emergency care throughout Michigan. The collaborative is funded by Blue Cross Blue Shield of Michigan and Blue Care Network through the Value Partnerships program.

In a new study published in Annals of Emergency Medicine, Drs. Kocher, Nypaver and a team of emergency physician MEDIC clinical champions from hospitals and health systems across Michigan use data from MEDIC to highlight opportunities to safely reduce overtesting in emergency departments.

The MEDIC team includes Brian O’Neil, M.D., the Munuswamy Dayanandan Endowed Chair of the Department of Emergency Medicine at Wayne State University and specialist in chief of Emergency Medicine at the Detroit Medical Center; Robert Sherwin, M.D., F.A.C.E.P., F.A.A.E.M., clinical associate professor of WSU Emergency Medicine and director of Clinical Research at Sinai Grace Hospital; and Rajan Arora, M.D., assistant professor of Pediatrics (Emergency) at the Wayne State University School of Medicine.

“We saw the MEDIC collaborative as a way to initiate evidence-based medicine protocols across the state of Michigan and track their results,” Dr. O’Neil said. “We had just recently initiated the use of the Canadian head CT rules within our emergency departments and were studying the use of a pulmonary embolism rule-out model based upon the use of Pulmonary Embolism Rule-out Criteria and Wells criteria. It has proven to reduce the use of CTA to rule out the condition at the Sinai Grace emergency department. It is our hope to roll our algorithm across the collaborative. Next we plan to modify a syncope rule to decrease the use of head CTs and hospital admissions.”

MEDIC warehouses a clinical registry containing data on more than 1 million emergency department visits from 16 emergency departments. It also includes data on performance across four quality measures for each department.

In the study, the research team examined data from the clinical registry, specifically looking at amounts of imaging. Estimates of excess imaging were calculated based on the Achievable Benchmark of Care method for determining quality improvement targets across a population.

In 2017 alone across the collaborative, the team found substantial variation in amounts of imaging and the potential to avoid 1,519 head CT scans for minor head injury, 3,308 chest X-rays for children with asthma, bronchiolitis or croup, and 4,254 CT scans for suspected pulmonary embolism.

“This translates to about $3.8 million annually in avoidable spending on low-value care if these MEDIC sites were to collectively improve to the benchmark standard,” Dr. Kocher said. “We show that there is the opportunity to avoid low-value imaging tests in the emergency department and, in turn, create significant health care savings.”

The study noted that measurement standards for patient care are increasingly tied to reimbursement, termed “pay for performance.”

“Unfortunately, these measures are often initiated and implemented without the direct input of the physicians they impact,” Dr. Kocher said. “It is critical that emergency physicians bridge this gap and participate in shaping how and in what form the quality of our care is measured and how it will positively impact our patients, or it will likely be determined for us by those outside of our specialty.”

Other MEDIC participants include: Beaumont Health, Royal Oak, Troy and Farmington Hills Hospitals; Detroit Medical Center, Children’s Hospital of Michigan, Detroit Receiving, Huron Valley-Sinai and Sinai-Grace Hospitals; Henry Ford Hospital, Detroit; Holland Hospital, Holland; Hurley Medical Center, Flint; Lakeland Medical Center, St. Joseph; Michigan Medicine, Ann Arbor; MidMichigan Medical Center, Midland; Munson Medical Center, Traverse City; and St. Joseph Mercy Hospital, Ann Arbor and Livingston.