Non-radiologist reads can increase resource utilization

The growing trend of emergency physicians interpreting ultrasound exams can lead to increased imaging utilization downstream, according to an article published in the Journal of the American College of Radiology.

Ultrasound is an invaluable tool for an emergency department: it’s quick, it’s cheap and it can be performed at a patient’s bedside. While emergency physicians have always read a small proportion of diagnostic ultrasounds, they nearly doubled their share of interpretations in the last two decades, from about 10 percent in 1990 to 18.4 percent in 2006.

Previous studies have associated emergency physician ultrasound reads with improved wait times or decreased length of stay in the emergency department, but a recent study led by Professor Bibb Allen Jr., MD, of the Department of Radiology at Grandview Medical Center in Birmingham, AL, found significantly less downstream imaging when initial emergency ultrasound exams are performed by radiologists.

“This difference was approximately 34 percent at seven and 14 days and 31 percent at 30 days,” the authors wrote. “The reasons behind these differences cannot be definitely elucidated using administrative claims data, but our results indicate that most of the additional imaging occurred within the first week after the patients’ ED visits.”

However, Allen stressed that the results aren’t an indictment on physician reads in an interview with Radiology Business Journal.

“There’s certainly arguments to be made that emergency department physicians performing ultrasound can be more efficient,” said Allen, who also is serving as President of the American College of Radiology and Chair of the Harvey L. Neiman Policy Institute's Advisory Board. “If you’re at a trauma center and you can do a quick ultrasound and they can see fluid in the abdomen and it obviates doing another study or it gets them to the top of the list for triage, those are all good things.”

The authors pointed to incomplete documentation of initial exams in the medical record or inappropriate exam choice as possible reasons for the increased imaging utilization—if the initial scan is missing or low-quality, the easiest course of action is often to simply re-do the exam. Instead of prompting a clampdown on non-radiologist reads, the study authors hope this will highlight the opportunity for increased collaboration and communication between sub-specialists.

“What radiologists need to recognize is that we are unlikely to be the sole owners of ultrasound forever,” said Allen. “One of the benefits we can bring to our health systems is ensuring the ultrasound preformed in our health systems is high quality.”

In his hospital, cardiologists, radiologists and vascular surgeons review endovascular interventional cases for quality assurance as part of a joint committee between the radiology, surgery and cardiology departments. This inter-departmental collaboration will be crucial to defining the landscape of emergency ultrasound moving forward, but that process is still in infancy, according to Allen.

“Radiology still preforms the vast majority of emergency ultrasound examinations; this is very early on in any sort of paradigm shift that could be occurring,” he said. “Once we learn more about imaging rates for specific exams, we can determine which would be best done by radiologists and which would be best performed by physicians.”