Head spin: Costs for ED dizziness visits hit $4B

A head-turning analysis has estimated annual national costs in the U.S. for patients presenting to the emergency department (ED) with dizziness at $4 billion. CT imaging, which is often ineffective and overused in these cases, accounted for $360 million in costs in 2011.

The study was published in the July issue of Academic Emergency Medicine.

The 2 million annual ED visits for dizziness or vertigo account for 4 percent of chief symptoms in the ED and require physicians to consider multiple causes, including stroke and cardiac disease. “Resource use, particularly neuroimaging, is increasing over time. These resources are not being used optimally, with mounting data suggesting brain CT is substantially overused,” wrote Ali S. Saber Tehrani, MD, from the department of neurology at Johns Hopkins University School of Medicine in Baltimore, and colleagues.

Tehrani et al sought to estimate the annual national costs associated with ED visits for dizziness.

The researchers mined the National Ambulatory Medical Care Survey to estimate costs for 1995 to 2009 and the Medical Expenditure Survey Panel for 2003 to 2008 data. They restricted the analysis to patients ages 16 years or older.

The primary outcome measures included the total annual costs of ED dizziness and vertigo in 2011 and attributable fraction of total national ED costs in 2011. The researchers also estimated the proportion of visits in which patients underwent neuroimaging.

The number of ED visits for dizziness and vertigo swelled from 2 million in 1995 to 3.8 million in 2009, without a clear shift in demographics toward an older population. CT use soared from 9.4 percent in 1995 to 37.4 percent in 2009, while MRI nudged from 1.2 percent in 1995 to 2.4 percent in 2009.

“From 1995 to 2011, the proportion of dizziness visits undergoing advanced imaging increased from 10.0 percent to 39.9 percent (4.0-fold increase) and the proportion of nondizziness visits undergoing advanced imaging increased from 3.4 percent to 19.0 percent (5.6-fold increase). Thus, dizziness visits are rising out of proportion to all ED visits, but advanced imaging for dizziness visits is not (although the imaging fraction for dizziness visits is double that for nondizziness).”

Cardiovascular diagnoses, which accounted for 16.5 percent of dizziness visits, had the highest per-visit cost and total annual national attributable cost at $940 million in 2011. Cerebrovascular diagnoses, 3.1 percent of visits, resulted in $127 million in costs.

Tehrani and colleagues suggested there may be opportunities to reduce the amount spent on CT imaging without affecting quality of care. Although CT is often used to rule out stroke, its sensitivity for acute ischemic stroke is approximately 16 percent. In addition, negative CT studies may falsely reassure physicians and exacerbate the risk of misdiagnosis.  

“Given known costs and radiation risks without clear benefit, optimal care would dictate that CT use should generally be curtailed in patients with dizziness, and guidelines should be developed to determine appropriate use,” wrote Tehrani and colleagues.

A clinical decision rule that curbed CT use in close to two-thirds of dizziness patients could eliminate nearly $200 million in costs each year, the researchers estimated. They added, “It is likely that controlling unnecessary costs for ED patients presenting with dizziness and vertigo will require systematic study of symptom-specific diagnostic algorithms and treatment pathways and may also require approaches that reduce unnecessary ED visits in the first place.”