Choosing wisely in emergency medicine: Early results and insights from the ACEP emergency quality network (E-QUAL)

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Highlights

  • Survey data from a large national sample of volunteer hospital-based EDs shows wide variation in imaging utilization

  • ED sites with sustained participation in a national QI initiative showed significant reductions in imaging utilization

  • Imaging utilization rates from top-performing ED sites can serve as performance improvement targets for future QI efforts

  • Efforts to translate the Choosing Wisely campaign into practice should utilize benchmarking to sustain practice improvements

Abstract

Purpose

To characterize performance among ED sites participating in the Emergency Quality Network (E-QUAL) Avoidable Imaging Initiative for clinical targets on the American College of Emergency Physicians Choosing Wisely list.

Methods

This was an observational study of quality improvement (QI) data collected from hospital-based ED sites in 2017–2018. Participating EDs reported imaging utilization rates (UR) and common QI practices for three Choosing Wisely targets: Atraumatic Low Back Pain, Syncope, or Minor Head Injury.

Results

305 ED sites participated in the initiative. Among all ED sites, the mean imaging UR for Atraumatic Low Back Pain was 34.7% (IQR 26.3%–42.6%) for XR, 19.1% (IQR 11.4%–24.9%) for CT, and 0.09% (IQR 0%–0.9%) for MRI. The mean CT UR for Syncope was 50.0% (IQR 38.0%–61.4%). The mean CT UR for Minor Head Injury was 72.6% (IQR 65.6%–81.7%). ED sites with sustained participation showed significant decreases in CT UR in 2017 compared to 2018 for Syncope (56.4% vs 48.0%; 95% CI: −12.7%, −4.1%) and Minor Head Injury (76.3% vs 72.1%; 95% CI: −7.3%, −1.1%). There was no significant change in imaging UR for Atraumatic Back Pain for XR (36.0% vs 33.3%; 95% CI: −5.9%, −0;5%), CT (20.1% vs 17.7%; 95% CI: −5.1%, −0.4%) or MRI (0.8% vs 0.7%, 95% CI: −0.4%, −0.3%).

Conclusions

Early data from the E-QUAL Avoidable Imaging Initiative suggests QI interventions could potentially improve imaging stewardship and reduce low-value care. Further efforts to translate the Choosing Wisely recommendations into practice should promote data-driven benchmarking and learning collaboratives to achieve sustained practice improvement.

Introduction

The Choosing Wisely campaign was launched by the American Board of Internal Medicine Foundation in 2012 to promote physician stewardship of healthcare resources by encouraging specialty societies to develop “Top Five” lists of low-value care practices amenable to avoidance. By 2014, the American College of Emergency Physicians (ACEP) had published ten evidence-based Choosing Wisely recommendations to promote resource stewardship and reduce low-value care in the emergency department (ED) [1]. Five of the ten items identified by ACEP were focused on the use of advanced imaging [2]. These recommendations were based on research demonstrating the potential overuse of imaging for several indications despite evidence-based guidelines to direct practice. One large national study demonstrated a 330% increase in CT utilization in the ED between 1996 and 2007 without improving diagnostic yield, and a study of Medicare beneficiaries found that the low-value services targeted by the Choosing Wisely initiative may contribute over $8.5 billion a year to annual health care costs in the Medicare program alone [[3], [4], [5]].

Since the inception of Choosing Wisely, emergency departments (EDs) across the country have initiated quality improvement (QI) efforts to implement recommendations in concert with national “Top Five” lists. These efforts are highly varied and include clinical pathways, computerized decision support tools, physician audit and feedback, and shared-decision making. While they showed promise in reducing potentially avoidable imaging within local contexts, efforts to identify and disseminate best practices have been limited and mostly confined to academic settings [6,7]. EDs that engaged in performance improvement initiatives to reduce imaging utilization also have few national benchmarks for comparison [8]. Finally, studies showed that while most ED physicians acknowledge overimaging as a problem, they are unaware of their own overutilization and continue to perform low value services [[9], [10], [11]]. Clinicians continue to be vulnerable to the “therapeutic illusion” of believing that their diagnostic tools are more effective than they actually are, resulting in unnecessary or costly care [12].

To address these gaps, The American College of Emergency Physicians (ACEP) Emergency Quality Network (E-QUAL) created the Avoidable Imaging Initiative in 2016 [13]. This initiative aims to establish national benchmarking data for imaging utilization using a large sample of hospital-based community EDs, disseminate common QI interventions, share best practices to reduce avoidable imaging, and report performance variation and improvement trends.

We sought to characterize imaging utilization performance and variation for QI efforts to reduce potentially avoidable imaging for Atraumatic Low Back Pain, Syncope, and Minor Head injury among ED sites participating in the ACEP E-QUAL Avoidable Imaging Initiative. We also sought to characterize top-performing ED sites to identify specific benchmarks for improvement and best practices associated with high performance.

Section snippets

Study design

This was an observational study of QI data obtained from a national learning network. Demographic, benchmarking, and survey data were collected from the E-QUAL database for all ED sites participating in the E-QUAL Avoidable Imaging Initiative in either 2017 or 2018, with data collected between December 2016 and December 2018. We focused on three clinical targets for imaging reduction within the initiative based on the ACEP Choosing Wisely list: Atraumatic Low Back Pain, Syncope, and Minor Head

Characteristics of study subjects

The characteristics of all participating ED sites are shown in Table 1. A total of 305 hospital-based EDs participated in the E-QUAL Avoidable Imaging Initiative in 2017 or 2018. Of these, 76 (25%) were small volume with <20 K annual visits, 157 (51%) were medium volume with 20-60 K annual visits, and 44 (14%) were large volume with >60 K annual visits. A total of 208 EDs (68%) were urban and 69 (23%) were rural. Only 1 ED group (0.3%) staffed a single ED, while 304 ED groups (99.7%) were part

Discussion

Despite the national attention generated by the Choosing Wisely campaign, imaging stewardship continues to be a controversial and challenging topic for the vast majority of EDs in the United States. The reduction of avoidable imaging is impeded by financial incentives that favor overutilization, requests from consulting and admitting physicians, overconfidence in imaging diagnostic capabilities, medicolegal risks, and the high capital cost of acquiring advanced imaging systems. These challenges

Conclusions

We found wide variation in imaging utilization performance among a large national sample of hospital-based EDs participating in the E-QUAL Avoidable Imaging Initiative. There was significant improvement among ED sites with sustained participation in the initiative from 2017 to 2018. Early evidence from this initiative supports the possibility of applying QI methods to improve imaging stewardship and reduce low-value care. Further efforts to translate recommendations of the Choosing Wisely

Sources of support

The project described was supported by Funding Opportunity Number CMS-1L1CMS331479-02 from the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of the US Department of Health and Human Services or any of its agencies. This award supports the American College of Emergency Physicians Support and Alignment Network (SAN) of the CMS

Meetings

None.

CRediT authorship contribution statement

Arjun K. Venkatesh: Conceptualization, Methodology, Project administration, Supervision, Writing - original draft, Writing - review & editing, Funding acquisition. Jean Elizabeth Scofi: Conceptualization, Methodology, Investigation, Writing - original draft, Writing - review & editing. Craig Rothenberg: Formal analysis, Validation, Investigation, Writing - review & editing, Visualization, Data curation. Carl T. Berdahl:Writing - review & editing. Nalani Tarrant: Data curation, Project

Declaration of competing interest

Dr. Venkatesh reports support from the Centers for Medicare & Medicaid Services for the development of hospital outcome and efficiency quality measures.

References (20)

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