Author Insights: Top 5 List of Diagnostic Tests That Emergency Physicians Can Forgo

Jeremiah D. Schuur, MD, MHS, department of emergency medicine at Brigham and Women’s Hospital in Boston, and colleagues created a top-five list of diagnostic tests they believe offer little value when assessing patients in the emergency department. (Image: Brigham and Women's Hospital)

Jeremiah D. Schuur, MD, MHS, department of emergency medicine at Brigham and Women’s Hospital in Boston, and colleagues created a top-five list of diagnostic tests they believe offer little value when assessing patients in the emergency department. (Image: Brigham and Women’s Hospital)

Diagnostic testing, treatments, and hospitalizations ordered by emergency physicians account for up to 10% of US health expenditures. From 2003 through 2011, the mean cost of an emergency department visit increased about 240%, from $560 to $1354. In an effort to rein in unnecessary and costly activities, an expert panel identified a top 5 list of tests, treatment, and disposition decisions (whether to admit patients to the hospital or discharge them) that they believe are of little value and can be controlled by emergency medicine physicians and avoided for most patients.

The list appears today in JAMA Internal Medicine.

The expert panel considered 64 tests, treatments, and disposition decisions before producing its top 5 list:

• Don’t order computed tomography (CT) of the cervical spine for patients after trauma who do not meet certain criteria
• Don’t order CT to diagnose pulmonary embolism without first determining a patient’s risk for pulmonary embolism
• Don’t order magnetic resonance imaging of the lumbar spine for patients with lower back pain without high-risk features
• Don’t order CT of the head for patients with mild traumatic head injury who do not meet certain criteria
• Don’t order tests to assess blood clotting times for patients without bleeding or unless you suspect they are on anticoagulation therapy or have a clotting disorder

The expert panel consisted of 7 emergency physicians practicing at 6 emergency departments in the Partners Healthcare health system in eastern Massachusetts; these 6 departments account for more than 320 000 annual patient visits. The panel members said their process provides a method that other emergency departments can use to identify targets of overuse that can be controlled by emergency physicians to improve the value of health care services delivered.

Lead author and expert panel member Jeremiah D. Schuur, MD, MHS, department of emergency medicine at Brigham and Women’s Hospital in Boston, discusses his team’s list.

news@JAMA: Why did you create a top 5 list of low-value clinical actions in the emergency department?

Dr Schuur: I read an article that really struck a chord with me on how physicians have a responsibility to be stewards of resources as part of our missions to improve health. So I thought it was important for emergency medicine physicians to do this. The article made a strong case for the idea that physician specialties largely control the knowledge and guidelines around much of what we do, and it was within our power to identify tests, treatments, and procedures that are not uniformly beneficial to patients. I thought the narrative of a top 5 list was a good way to get the message across.

news@JAMA: You emphasize “actionability.” What is it, and how does it pertain to your list?

Dr Schuur: Actionability is important in emergency medicine because we practice in close collaboration with many other specialties and rely on other practitioners and institutions to continue care. For example, ordering preoperative testing is something emergency physicians often order when a patient will be admitted. And while we may place the orders, ultimately the surgical admitting service is making the decisions of what needs to be ordered. So, we thought, the average practicing emergency physician is not going to be able to change that dynamic. On the other hand, for example, many who present with head injuries get treated and released, and the emergency physician is responsible for all the decisions.

news@JAMA: Might emergency physicians be hesitant to embrace the recommendations in your top 5 list for fear of being sued for not doing everything possible when treating a patient?

Dr Schuur: I understand physicians fear malpractice, but our recommendations are structured such that you can avoid doing those things safely. The best way to avoid medical liability is to practice high-quality medicine, and the top 5 items we chose are strongly supported by clinical evidence.



Categories: Computed Tomography, Emergency Medicine, Magnetic Resonance Imaging, Quality of Care