Wednesday, June 29, 2005

Overdose (of Imaging) in the ER

Dr. Joel Schwartz, writing in response to an article in Diagnostic Imaging about subspecialty ER radiology, touched upon a nerve. He writes, in part,

What Dr. Trefelner (in the original DI article) does not mention is the very low rate of positive studies for ER patients. (At our hospital, ER and private physicians order studies on patients in the emergency room.) A recent review of 1600 studies ordered from our emergency room between 5 p.m. and 8 a.m. over a 10-week period revealed pulmonary embolism in just 6.25% of pulmonary angiograms, acute findings in just 7.1% of cervical spine CTs, and acute findings in just 6.7% of pediatric emergency room head CTs. None of 27 patients who had combined chest, abdomen, and pelvis CT scans had acute surgical abnormalities. The conclusion is obvious: There is an extremely low percentage of acute findings on studies ordered from the ER. The problem is not on the interpretation side but on the ordering side....

It would be unacceptable for any radiologist in my group to recommend additional imaging that would be negative 90% of the time. Yet, after an initial ER evaluation, ER physicians are sending patients for radiological evaluation where 90% have no significant abnormality identified.

The reason for the high ordering of studies is most likely multifactorial. Dr. Trefelner talks about lack of subspecialization in radiology, when, in fact, a lack of expertise by ER physicians and nurse practitioners accounts for some of the overordering. The subject of liability always arises during discussions of utilization with our ER physicians. Staffing and limited time may also contribute to the ER's reliance on imaging. I do not think radiological interpretation plays a significant role.

Now, I have many friends among our ER staff, and I don't want to slam them in this manner. (They might well find ways to get revenge at 3 AM the next time I'm on call!) Still, I have run similar reviews on CTA's for pulmonary embolus and on head CT's at our main hospital, and lo and behold, we too have an approximately 5% rate of positives.

As Dr. Schwartz notes, there are numerous reasons for this overload of mostly negative studies, and he seems to place blame squarely at the feet of the ER docs. I think there is much more to it than that.

A bit of history is in order. In 1986, Congress enacted the Emergency Medical Treatment and Active Labor Act (EMTALA), which mandates hospitals (especially ER's) to treat anyone who needs care, whether or not the patient can pay. Depending on how you look at it, this could well be the most expensive unfunded mandate in United States history, essentially establishing a limited form of socialized medicine. Unlike Hilary's plan, or the Canadian or British systems, funding comes from the providers, the hospitals and the doctors, rather than the federal government. There are ways the hospitals are compensated by tax money, but the docs have to simply write off the care of those who cannot pay. The bottom line here is that anyone who walks, crawls, or otherwise arrives at the ER gets care. Period. Now, don't get me wrong, this is definately a good thing. In the bad old days, acutely-ill patients could be dumped to another (usually the county) hospital, and on occasion they didn't live long enough to get there. EMTALA was designed to eliminate this horrendous practice, and it has done so. In the process, however, we have created somewhat of a monster. My fellow blogger, Mad House Madman (an internist) puts it thus:

...unfortunately, many in our community have made the Emergency Department their primary care provider. They come to the emergency room to obtain care for non-emergent problems. This is unfortunate because the ER was not intended to provide this care and, often, they will simply stay out in the waiting room for hours on end to obtain a prescription, or seek medical advice about routine medical issues. More worrisome is the fact that many will end up receiving unnecessary tests to rule out emergent disease, as this is the primary goal of the emergency room physician. These tests carry risk, and increased cost. For example, last night a lady waited in the emergency room for treatment of acute diarrhea that she’s had from the morning. She was finally seen at ten at night. She was given Imodium, which stopped the diarrhea. However, someone noticed that her oxygen saturation was low, which led to a Doppler, and then a spiral CT scan. Nothing turned up. Forty hours and four hundred dollars later, she finally went home, free of her bowel difficulties.

There are two things working against common sense here. First, you have a patient who comes into the ER expecting to be fixed (as in made well, not the other definition). Second, you have the ER doc who wants to fix the patient. The patient comes in with certain expectations: "My (fill in the blank) hurts, the doctor needs to do something that looks at my (fill in the blank) so he can fix it. And by the way, since I've waited four hours to see the doctor, I would like this done NOW." One of my friends among the ER staff told me that he used to have patients with clearly non-acute abdominal pain return at 7AM for their obligatory gallbladder ultrasound. Many of the patients subsequently complained to the administration of the hospital that my friend "didn't feel their pain". He was forced to order emergent studies after that. I'll wager he never got a surgeon to remove those few hot gallbladders he might have found until well after 7AM the next day. Sadly, there are those patients who abuse the system, although they might not see it that way. Consider the patient whose X-ray jacket (or PACS study-list) contains 20 head CT's over the past 5 years, all of which are negative. He presents today with a "really, really bad headache, the worst I ever had, Doc!" I will guarantee that he will receive his 21st scan, and it will be negative. Again. (This is not an exaggeration, by the way.)

The ER docs feel they must "give" the patient something so they will leave happy; patients expect such treatment as a reward for their, uhhh, patience. Add that to the fear of litigation for missing something, and you have a recipe for the 95% negative scan rate.

How do we solve this? It is far from easy, but I think the first step is to recognize that the vast majority of these scans are negative. That is not to say that 95% of the scans were unnecessary, but obviously there must be a significant percentage of studies that simply didn't have to be done. Dr. Schwartz concluded in his letter:

I would like to see the ASER, ACER, or American College of Radiology develop imaging algorithms for emergency room patients. These could serve as acceptable guidelines and hence act as reasonable standard of care. These would protect the emergency physician from liability, protect patients from unnecessary imaging, and maximize resource utilization. I would also like to see guidelines for measuring the utilization of the more expensive and resource-hungry examinations. Guidelines that set targets for the number of studies with positive results could serve as goals for ER physicians.

Certainly a good place to start. Now, how do we keep the public from using the ER as their primary physicians, coming in with every little complaint? That is probably the harder question. Education will help, but in the end, Americans have come to believe that high-level health care for any and all problems at any time of the day or night is their God-given right. It's a nice idea, but sooner or later, we may run out of resources to make that happen. Then what?

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