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Patients and Not Physicians, Main Determinant in Emergency Department Imaging Usage

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Based on a study published online in the journal Radiology, points out that contrary to popular belief, very little of the diversity in Emergency Department (ED) imaging usage is associated with physician experience, training or gender.emergency department

Imaging exams and systems such as CTs or X-rays are employed quite often in the ED. In 2010, a little more than 47 percent of all ED visits in the U.S. had an imaging exam via CT or X-ray.

"Analyzing and understanding drivers of use of imaging in the ED is important for several reasons. There's a balance of cost and benefits to the patient, institution and payer, as well as the overarching issue of radiation exposure,” said member of the departments of radiology at Massachusetts General Hospital in Boston and the University of Florida in Gainesville, Fla, Christopher L. Sistrom, M.D., M.P.H., Ph.D.

Prior studies have shown significant differences in imaging rates from all EDs, alluding to a variety of approaches physicians take when ordering imaging, despite there being a limitation in present research.

"A lot of literature on imaging variability can lead to a false assumption that doctors are primarily responsible. The problem is that it is difficult to fully describe and quantify variability at the different levels it can occur,” said Sistrom.

Sistrom and his team examined 88,851 ED visits during 2011 at Massachusetts General Hospital. They employed an analytical tool referred as hierarchical logistic regression to distinguish several signs of the possibility imaging was ordered during a given visit.

"That's what makes our paper unique. Hierarchal modeling allows us to ask very specific questions about the relative contributions of various factors to imaging use,” commented Sistrom.

The overall rate of imaging usage in the Massachusetts General ED was 45.4 percent in 2011, very much like the 2010 national average of 47.2 percent. Deciphering of the results showed that factors often attributed to physicians such as gender, experience and training had no affiliation with how imaging systems were utilized.

"The key finding in our study is that doctors don't make much difference in imaging utilization. Our data showed that doctors are responsible for about one percent of the variability in probability of having an imaging exam during an ED visit,” noted Sistrom.

Moreover, it was patients who were seen as the determinants of ED imaging as prior visit, referral source, arrival mode and clinical reason for the visit all accounted for ED imaging usage.

Another contributing element to imaging usage was the workload found in the ED; as odds of low-cost imaging were 11 percent greater than the given standard when the ED wasn’t too busy. But a busier ED would typically lead to higher-cost imaging.

The study examines medical management that look to diminish image utilization may be misinformed on concentration on interceding with ED physicians.

"To reduce imaging utilization, a lot of people in quality improvement and medical management might try to identify high outliers and punish them. In settings like the one we studied, that strategy won't get you anything but angry doctors,” concluded Sistrom.

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