Use of Neuroimaging for Patients With Dizziness Who Present to Outpatient Clinics vs Emergency Departments in the US

Abstract

IMPORTANCEOveruse of costly neuroimaging technology is associated with low-value care for the prevalent symptom of dizziness. Although quality improvement initiatives have focused on the overuse of computed tomography (CT) scans in emergency departments (EDs), most patients with dizziness present to outpatient clinics. To inform practice and policy, a comprehensive understanding of the uses and costs of neuroimaging across settings and episodes of care is needed.OBJECTIVE To characterize neuroimaging use, timing, and spending as well as factors associated with imaging acquisition within 6 months of presentation for dizziness in outpatient vs ED settings. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of commercial and Medicare Advantage claims for 805 454 adults (Ն18 years of age) with new diagnoses of dizziness was

Diagnostic accuracy of neuroimaging in emergency department patients with acute vertigo or dizziness: A systematic review and meta‐analysis for the guidelines for reasonable and appropriate care in the emergency department

“…Currently, misdiagnoses are frequent and diagnostic testing costs are high. 2,10,11 Unfortunately, clinicians overrely on the utility of noncontrast computed tomography (CT) of the head as well as in CT angiography (CTA) for these patients. 12,13 Furthermore, the use of neuroimaging for ED patients with dizziness has not been associated with more stroke diagnoses.…”

“…The total neuroimaging spending for this population was $88 million, with magnetic resonance imaging (MRI) accounting for 70% of the cost. 10 We aimed to conduct a systematic review and meta-analysis of the diagnostic test accuracy of different neuroimaging modalities for adult patients presenting with acute vertigo or dizziness to the ED. This evidence synthesis was conducted to inform the recommendations for the third Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-3).…”

Video-Oculography to Guide Neuroimaging for Dizziness and Vertigo

“…In this issue of JAMA Otolaryngology–Head & Neck Surgery , Adams et al add to the substantial body of literature showing that imaging is overused in dizziness presentations across clinical care settings, at great cost to the health care system. The authors used an administrative claims database to assess neuroimaging use for a large cohort (805 454 adult patients with commercial or Medicare Advantage insurance from 2006 to 2015).…”

“…Those familiar with this topic will know that CT scans miss more than 80% of posterior fossa strokes and provide mostly a false sense of reassurance to clinicians when the results are normal; clearly, that is no solution. They will also know that MRI is far more accurate for stroke diagnosis, capturing 80% of strokes in the first 24 hours and nearly 100% if obtained in an optimal 3- to 7-day time frame after onset of symptoms; however, Adams et al have deftly pointed out that MRI accounts for 70% of current neuroimaging costs (despite accounting for just 35% of tests), so any solution that relies on switching from a CT scan–based diagnosis to an MRI-based diagnosis is likely to balloon costs, in spite of plummeting reimbursements. Ballooning costs would be bad because total spending, if extrapolated from the results in the study by Adams et al to 18 million annual visits in the US, already translates to roughly $2 billion per year for current imaging.…”

“…The tougher question, however, is how to best disseminate these proven bedside techniques. Adams et al allude to many options, including telemedicine, decision support tools, machine learning, targeted education, practice guidelines, quality metrics, payment incentives, and eye movement recordings via video-oculography (VOG). It is the last of these that deserves special attention because VOG offers the best opportunity to ultimately facilitate, enhance, and/or undergird the other solutions.…”