Radiology Utilization in the Emergency Department: Trends of the Past 2 Decades

Abstract

Objective To assess radiology utilization trends for emergency department (ED) patients from 1993 through 2012. Methods In this institutional review board-approved, retrospective study at a 793-bed tertiary care academic medical center, we reviewed radiology utilization from January 1, 1993 through December 31, 2012, during which time the number of ED patient visits increased from 48,000 to 61,000, and determined the number of imaging studies by modality (x-ray, sonography, CT, MRI, other) and associated relative value units (RVUs). We used linear regression to assess for trends in the number of imaging RVUs and imaging accession numbers, our primary and secondary outcomes, respectively. Results The total RVUs attributable to ED imaging per thousand ED visits increased 208% from 1993–2007 (p<0.0001) and then decreased 24.7% by 2012 (p<0.0019). The total number of imaging accession numbers per thousand ED visits increased 47.8%from 1993 until 2005(p=0.0003), then decreased 26.9% by 2012 (p<0.0001). CT RVUs per thousand ED visits increased 493% until 2007 (p<0.0001) and then decreased 33% (p<0.0001), MRI RVUs increased 2,475% until 2008 (p<0.0001) and then decreased 20.7% (p<0.032). Ultrasound RVUs increased 75.7% over the study period (p<0.0001) while x-ray RVUs decreased 28.1% (p=0.0009). Conclusions Following a period of substantial increase from 1993–2007, volume-adjusted ED imaging RVUs declined from 2007–2012, largely due to decreasing use of CT and MRI. Further studies are needed to determine the causes of this decline, which may include quality improvement activities, advocacy for appropriateness by leadership, concerns regarding radiation exposure and cost, and health IT interventions.

Introduction of a Dedicated Emergency Department MR Imaging Scanner at the Barrow Neurological Institute

“…B, Prior MR workflow: central porter collects the patient (1); porter, patient, and nurse go to MR imaging (2); nursing handover with MR imaging nurses (3); nurse goes to ED, porter goes to Central Transport (4); ED nurse and central porter go to MR imaging (5); nursing handover with MR imaging nurses (6); porter, patient, and nurse go to patient's bed (7); porter goes to Central Transport (8). C, ED MR imaging workflow: ED porter collects the patient (1); porter, patient, and nurse go to ED MR imaging (2); porter, patient, and nurse go to patient's bed (3); porter goes to ED Transport (4).…”

“…This argument merits attention, and other interventions such as persistent physician education, clinical decision support, updated guidelines, and pay-for-performance systems have been shown to be effective in decreasing use in academic centers. 3,4 However, the issue of increased use is multifactorial, and a permanent solution would likely require systematic changes to payment structures and extensive alterations in the medicolegal landscape, both of which are extremely complex environments. Fast access to MR imaging from the ED has, at least in the interim, provided a safer and diagnostically superior replacement for CT.…”

“…1,2 This trend has outpaced the increasing number of ED visits, indicating that at least part of this rise is due to increasing demand for these imaging tests. 3 While this increasing use has been successfully reversed in some centers with education programs, clinical decision support systems, pay-for-performance incentive systems, and other methods, 3,4 national data continue to demonstrate growth, most notably in CT. 1 Neuroimaging makes up a substantial portion of this use, constituting a large proportion of total CT imaging 3,5 and most MR imaging ordered in the ED. 2,5 These trends have led to increasing concern regarding the rising health care costs and the radiation dose attributable to increasing CT use.…”

Computed Tomography and Shifts to Alternate Imaging Modalities in Hospitalized Children

“…The remaining half of the APR-DRGs were associated with a decrease in CT that exceeded increases in ultrasound/ MRI, suggesting that it was not only a desire to avoid ionizing radiation that drove the decision to not use CT, but a general decline in imaging volume. 39 Other factors also may be at play, such as new or updated national guidelines discouraging routine use of CT for simple febrile or first nonfebrile seizure, 40,41 or the growing use of imaging appropriateness criteria [42][43][44][45][46] and clinical pathways in emergency department and inpatient settings that provide guidance and evidence base for the use or nonuse of certain diagnostic approaches.…”

Optimizing Diagnostic Imaging in the Emergency Department

“…However, there has been concern about the increasing utilization of diagnostic imaging in the United States, particularly in the emergency department (ED). 1-5 The increasing use of diagnostic imaging has led to increased costs 6 and ED lengths of stay, 7 but up to 50% of diagnostic imaging may be medically “unnecessary,” 8 and the increasing use of diagnostic imaging has not led to better identification of pathology nor an improvement in patient-centered outcomes. 5,9 Computed tomography (CT) use, specifically, also increases patient exposure to contrast media and the associated risk of contrast-induced nephropathy.…”