Top-five list aims to improve value of emergency care

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A technical expert panel has determined five clinical actions that are of low value and within the control of emergency department health care providers to identify additional actionable targets of overuse in emergency medicine, according to a study published by JAMA Internal Medicine on Feb. 17.

As the cost of healthcare in the U.S. continues to rise, particularly in emergency departments, steps are being taken to eradicate unnecessary and costly tests or procedures. Lead author Jeremiah D. Schuur, MD, MHS, of Brigham and Women’s Hospital in Boston, and colleagues strove to identify a top-five list of tests, treatments, and disposition decisions that are frequently ordered by emergency clinicians, have a significant expense, and provide little or no benefit to patients.

Results from the study, which included a survey of 283 emergency medicine clinicians from six emergency departments, aided in forming the following five recommendations for emergency physicians:

1. Do not order CT of the cervical spine for patients after trauma who do not meet high-risk criteria.

2. Do not order CT to diagnose pulmonary embolism without first determining the patient’s risk for pulmonary embolism.

3. Do not order MRI of the lumbar spine for patients with lower back pain without high-risk features.

4. Do not order CT of the head for patients with mild traumatic brain injury who do not meet high-risk criteria.

5. Do not order anticoagulation studies for patients without hemorrhage or suspected coagulopathy.

“Developing and addressing a top-five list is a first step to addressing the critical issue of the value of emergency care,” wrote Schurr and colleagues.

Next steps include the adoption of evidence-based decision support to electronic medical records in hospitals so that providers have best evidence cues when ordering tests, making the cost and use of these procedures visible to providers, and changing societal perception regarding medicine.

“We need to change society’s expectation that medicine will never miss a diagnosis,” Schurr told Health Imaging. “As long as providers are worried about getting sued or reprimanded for missing a one in 1,000 diagnosis, many providers will continue to order tests that have minimal benefits.”

In an associated editorial, Deborah Grady, MD, MPH, of the University of California-San Francisco, and colleagues wrote: “We hope the article by Schuur et al will stimulate other professional societies to adopt clear, transparent methods for developing and revising top-five lists with substantial input from practicing clinicians.”