Examining utilization: 3 key trends in ED cervical spine imaging

More than one million U.S. patients are treated in EDs each year for potential cervical spine injuries, and cervical spine imaging exams are often ordered to treat those patients. 

However, according to a recent study published by the Journal of the American College of Radiology, there is a lack of information on national trends in the utilization of cervical spine imaging and how it has been impacted by changing attitudes and evolving technology.

“Filling such knowledge gaps may prove important in optimizing future health care delivery systems and appropriately allocating costs and manpower in an era of bundle-paid care,” wrote Paul Harkey, MD, department of radiology and imaging sciences at the Emory University School of Medicine in Atlanta, and colleagues.

Harkey and colleagues decided to jump into the data themselves, examining Medicare claims for ED cervical spine imaging from 1994 to 2012.

These are three trends the authors discovered in their research:

1. Utilization more than tripled from 1994 to 2012

There were more than 210,000 ED cervical spine imaging exams performed in the Medicare fee-for-service population during 1994, and that number jumped to more than 730,000 in 2012.

“Per 1,000 Medicare fee-for-service beneficiaries, the utilization rate for all ED cervical spine imaging increased 242 percent from 6.5 to 22.3,” the authors wrote.

2. Most exams are billed by radiologists, and that number is still on the rise

Harkey et al. also noted that, in 1994, more than 91 percent of the exams were billed by radiologists. Emergency physicians made up more than 3 percent, and all other specialties combined for more than 4 percent.

Over the course of nearly two decades, those numbers became even more lopsided; by 2012, radiologists were responsible for more than 98 percent of ED cervical spine imaging exams, and emergency physicians billed less than one percent.

3. Radiography utilization increased, but then declined; CT and MR both increased

Radiography claims increased by more than 50 percent from 1994 to 2004, but then declined by more than 50 percent in the next eight years. Overall, more than 200,000 total radiography exams in 1994 dropped to more than 152,000 claims in 2012.

CT, meanwhile, skyrocketed from more than 6,000 claims in 1994 to more than 570,000 in 2012. MR utilization increased as well, though not to the same degree as CT; there were more than 900 claims for MR in 1994 and more than 13,000 in 2012.

“Improved scanning efficiency along with a surge of recent literature highlighting the diagnostic advantages of CT and MR in detecting clinically significant cervical spine abnormalities have likely driven the increased utilization of these modalities,” the authors wrote. “Increased marketplace technology penetration, with CT scanning now available at even most rural critical-access hospitals, has improved patient access to advanced imaging and likely also contributed to the dramatic growth of CT. Although the utilization of MR has also grown dramatically, it still represents only a very minor portion of cervical spine imaging performed in the ED setting.”

Harkey and colleagues said their study had several limitations. For example, their focus was limited to the Medicare fee-for-service population.

“Trends in other payer populations in the ED setting could differ, but we have no specific reason to believe that this is the case,” the authors wrote.

In addition, since the claims data relied on self-reported codes, there is the possibility that providers made coding errors, but researchers were unable to detect them.