Benchmarking and Overuse in Emergency Medicine

May 21, 2020

Since the American College of Emergency Physicians (ACEP) released 10 Choosing Wisely recommendations in 2013/2014 —half of which involved imaging— many emergency departments have launched quality improvement programs to reduce their use of unnecessary scans. But they lacked baseline data that enabled them to compare their performance to other emergency departments (EDs). ACEP’s Emergency Quality Network (E-QUAL) sought to fill this data gap through its “Avoidable Imaging Initiative,” launched in 2016.

Through the initiative, ACEP sought to create national benchmarking data on imaging for low back pain, syncope and minor head injury, using a sample of 305 hospital-based community emergency departments. It also disseminated simple quality improvement (QI) interventions, shared best practices in reducing avoidable imaging, and reported on performance variation and improvement trends.

A recent study in the American Journal of Emergency Medicine analyzed results from 2017 and 2018, and found improvements in some areas alongside widespread variation in utilization. Participants could choose any intervention (e.g., clinical decision support, physician audit and feedback); they often selected activities that fit their local resources and interests or aligned with Medicare payment programs.

The authors found significant performance improvement in CT utilization for syncope and minor head injury from 2017 to 2018, but no significant change in imaging for low back pain. However, MRI utilization rates for low back pain were already quite low.

“Our results for Atraumatic Low Back Pain were the most surprising,” said Arjun K. Venkatesh, MD, MBA, the study’s lead author and a member of Yale Medicine’s emergency department. “We were pleasantly surprised to find that the average MRI utilization rate remained low (0.9%) across our sample, which runs counter to the common myth that MRIs are overused in the ED.”

Dr. Venkatesh said that there were also less pleasant surprises. “We were also surprised by the fact that so many EDs joined our movement nationally yet they continued to face challenges in basic improvements to reduce potentially avoidable imaging such as the challenges of inadequate clinical practice guidelines or access to hospital data needed for improvement,” he said.

One of the study’s co-authors stressed the variation among EDs. “The gap in imaging utilization rates between top versus bottom performers were large across all three of our clinical targets, even among our highly motivated sample of E-QUAL participants,” said Jean Elizabeth Scofi, MD, who also practices emergency medicine at Yale. “This further underscores the importance of identifying national benchmarks for imaging performance that can help us translate the Choosing Wisely recommendations into real-world practice.”

Both researchers said that their results should be interpreted with caution as their sample draws from voluntary participation and self-reporting, adding that the participants’ imaging performance was likely more appropriate than that of EDs generally. With more data from a larger number of ED sites, they believe they can develop even more robust national benchmarking standards for performance improvement goals.

“We plan to expand the number of participating EDs and improve data collection to better characterize national QI activity engagement and best practices. We also hope to report benchmarking data for more clinical targets in future years, including ACEP’s targets for improving imaging value in treating renal colic and syncope,” Dr. Scofi said.

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