Emergency imaging “superusers”: A serious concern about imaging resource utilization
If names of patients having emergency imaging seem to be familiar to radiologists interpreting their exams, it is very possible that they are. A study from Emory University School of Medicine in Atlanta, GA, of nearly 127,000 emergency patients revealed that half of all emergency department imaging services at Emory’s four hospitals in 2016 were of only 12% of this group. These emergency department “superusers” are described in an article published online November 15th in Emergency Radiology.
Principal investigator Tarek N. Hanna, MD, associate director of the Division of Emergency and Trauma Imaging, and colleagues conducted a study analyzing emergency department (ED) clinical and imaging usage patterns at Emory’s four affiliated hospitals in 2016. A total of 126,940 patients had 192,142 imaging exams performed during 187,603 visits to the hospitals’ emergency departments. Four hundred eight patients visited an emergency department more than 10 times, accounting for nearly 4% of all ED visits.
The authors identified 2,007 “clinical superusers,” individuals who visited an emergency department more than four times annually. These patients accounted for 7.7% of the total number of visits, although they represented only 1.6% of the patients. They underwent an average of 6.8 imaging exams per visit compared to 1.5 exams for the other 98%.
A different subgroup, “imaging superusers,” included 1,608 patients, or 1.3% of the total. During their annual ED visits, they had 23,787 imaging exams, or 12.4% of all imaging services for ED patients performed by the four hospitals. The overlap between the clinical ED superusers and the imaging ED superusers was quite small, with only 472 patients identified in both categories.
The source of payment for clinical ED superusers and patients who visited an ED less than four times annually differed considerably. There was a significantly higher percentage of clinical ED superusers who had government-provided health insurance (Medicaid - 20% and Medicare - 42%) compared to low usage patients (Medicaid - 6% and Medicare - 26%). Only 26% of superusers had private health insurance compared to 59% of low usage patients.
Patients with Medicare had the highest level of utilization for four or more examinations. Private insurance coverage was nearly comparable for patients having one to three imaging exams annually. Medicaid patients had fewer exams than patients covered by private insurance or Medicare.
The authors wrote that imaging superusers who had more than 10 imaging exams annually “warrants a more detailed characterization to optimize imaging utilization in the ED, prevent unnecessary patient radiation exposure, and constrain healthcare cost growth.”
“We are currently conducting an analysis of a national claims-based database to examine the frequency and characteristics of heavy users of Emergency Department imaging on a national level,” Dr. Hanna told Applied Radiology. “Through this robust database, we hope to further identify clinical and demographic characteristics of individuals who undergo disproportionate amounts of ED imaging.”
Dr. Hanna said that Emory has not yet implemented a program to identify ED imaging superusers and initiate interventions when clinically appropriate. “We hope that as we refine this concept, this may become possible,” he said.
“There are multiple possibilities for intervention or application of these data. First, if we prospectively identify ‘ED Imaging Superusers’, this population could be flagged in the medical records and providers would know when such an individual appeared in the Emergency Department,” he said. “At that point, the emergency provider could use this information in concert with other clinical signs/symptoms to determine if imaging during a patient’s ED visit was warranted. Second, these patients could be identified on a health-system basis. Their charts and clinical care could be examined to ensure that they were receiving optimal care and appropriate imaging. Third, if we identify patterns in excessive ED imaging use at a national level, this may have broader health policy and practice implications which can benefit individual patients.”
REFERENCE
- Hanna TN, Kundu S, Singh K, et al. Emergency department imaging superusers. Emerg Radiol. Published online November 15, 2018. doi: 10.1007/s10140-018-1659-y.