In the United States, studies have shown that test-ordering rates vary considerably throughout emergency medicine (EM), and advanced imaging use continues to increase despite little evidence suggesting that it improves patient outcomes. “The reasons for this are multifactorial,” explains Hemal K. Kanzaria, MD, MS. “They may include malpractice fears and a desire for diagnostic certainty. Regardless of the rationale, there has been a strong push within EM to address over-imaging and to provide high-quality care.”
Efforts are being made throughout the U.S. to improve value in healthcare, but Dr. Kanzaria says few studies have explored the viewpoints of practicing emergency physicians (EPs) regarding their role in reducing low-yield diagnostic testing. “Understanding what physicians think about this issue is a crucial step to decreasing over-testing,” he says. “A better understanding of these beliefs would help us in achieving the larger goal of providing high-value, patient-centered care.”
Taking a Closer Look
In a survey study published in Academic Emergency Medicine, Dr. Kanzaria and colleagues investigated the perceptions of EPs, exploring the extent to which they order “medically unnecessary” advanced diagnostic imaging. This was defined as ordering of CT and MRI tests that physicians would not order if they had no external pressures and could focus only on providing optimal medical care. The investigators also asked EPs about factors that contribute to this behavior and solutions that would be most effective at curbing this practice.
According to the results, more than 85% of respondents believed that, in general, too many diagnostic tests were ordered in their own EDs, and 97% reported that at least some of the advanced imaging studies they personally order were medically unnecessary. The primary perceived contributors were fear of missing a low-probability diagnosis and fear of litigation. “Over-testing is not due to physician lack of knowledge or insight, or to poor medical judgment,” Dr. Kanzaria says. “Rather, it reflects a cultural response, both within and outside of medicine, to error and uncertainty.”
The surveyed EPs also suggested several solutions that they believed would be “extremely” or “very” helpful for reducing unnecessary imaging. “These included tort reform and increasing patient engagement through education and shared decision-making,” says Dr. Kanzaria. Other possible strategies recommended by respondents included receiving feedback on test-ordering metrics and improving physician education on diagnostic testing (Figure).
A Systematic Problem
“Over-imaging is likely a systemic problem, not a problem of bad doctors,” explains Dr. Kanzaria. “The finding that so many surveyed physicians acknowledged ordering tests for non-medical reasons suggests that there are larger systems or cultural drivers to over-testing. To fix the problem, we need to address these drivers rather than scold physicians. To stop the practice of over-testing, we need to address both our societal intolerance of uncertainty as well as the culture of blame the malpractice system propagates.” He adds that no single approach will help curb the issue effectively. There needs to be a collaborative effort in which multiple aspects of the problem are simultaneously addressed.
The study identified several potential solutions to the problem of over-imaging in the ED. For example, in addition to tort reform, it would be useful to educate EPs on their actual risk of legal liability and the fact that it is likely lower than the perceived risk. To address fears of uncertainty and a desire for improved training on diagnostic testing, several resources have become available for EPs, including tools from the Society for Academic Emergency Medicine. These resources provide systematic approaches to understanding diagnostic test utility for common ED diagnoses.
More Research Needed
A recent call to action has been issued for developing quality measures that encourage more efficient use of diagnostic imaging in EDs. “It’s important to gain a better understanding of the insights and beliefs of practicing EPs on solving these issues in order to improve quality of care,” Dr. Kanzaria says.
Studies are needed to evaluate whether formal training on probabilistic decision-making could help physicians cope better with uncertainty and decrease unnecessary testing. The authors also suggest evaluating ways to incorporate shared decision-making in emergency care. In addition, offering EPs feedback on test-ordering metrics has the potential to reduce over-testing. Such efforts could further increase quality of care in EM and help EPs achieve high-value care.
Kanzaria HK, Hoffman JR, Probst MA, Caloyeras JP, Berry SH, Brook RH. Emergency physician perceptions of medically unnecessary advanced diagnostic imaging. Acad Emerg Med. 2015;22:390-398. Available at: http://onlinelibrary.wiley.com/doi/10.1111/acem.12625/abstract.
Hoffman JR, Kanzaria HK. Intolerance of error and culture of blame drive medical excess. BMJ. 2014;349:g5702.
Hess EP, Marin J, Mills A. Medically Unnecessary Advanced Diagnostic Imaging and Shared Decision-Making in the Emergency Department: Opportunities for Future Research. Acad Emerg Med. 2015; 22:475-7.
Kanzaria HK, Brook RH, Probst MA, Harris D, Berry SH, Hoffman JR. Emergency physician perceptions of shared decision-making. Acad Emerg Med. 2015 Mar 23 [Epub ahead of print].