Nearly one-third of emergency department encounters for ministrokes across the U.S. include redundant brain imaging and addressing this trend could help reduce rising healthcare costs, experts wrote Tuesday.
Multiple guidelines have been published to address the proper use of imaging for transient ischemic attacks while avoiding overuse. And previous studies have recorded increasing compliance with these guidelines, alongside a “substantial” rise in the use of radiology resources, according to a new study in JACR.
Wanting to characterize the most common combos of imaging used for ministroke workup, University of Colorado researchers looked to nationwide ED data. They found eye-opening results: In 2017 alone, U.S. providers tallied nearly $8.7 million in charges for unnecessary scans of ministroke patients.
“In summary, we observed likely redundant use of noncontrast brain imaging in nearly one-third of encounters for workup for [transient ischemic attacks] across EDs in the United States,” Vincent Timpone, MD, with the Department of Radiology at the University of Colorado Hospital in Aurora, and co-authors wrote July 27. “Reducing redundant neuroimaging in TIA may help to mitigate rising ED healthcare costs, particularly in patient groups and hospitals with increased resources, where overutilization of imaging is more prevalent.”
For their study, researchers tapped the Nationwide Emergency Department Sample database, the largest all-payer ED sample in the country comprising more than 30 million annual visits. Timpone et al. pinpointed brain and neurovascular imaging using current procedural terminology codes and defined redundant imaging as an ED encounter with any duplicate cross-sectional brain, brain-vascular or neck-vascular imaging.
Emergency providers discharged nearly 185,000 patients with ministrokes in 2017, with redundant imaging observed in about 30% of encounters. Meanwhile, redundant brain-vascular and neck-vascular imaging was found in about 2.8% and 0.7% of ED encounters, respectively. Patients had decreased odds of obtaining unnecessary scans if they were on Medicaid (odds ratio of 0.72), treated at non-trauma centers (0.49), a rural hospital (0.18), or over the weekend (0.9).
Tracking numbers across the study period, researchers found that redundant brain imaging for patients with TIA climbed from 2.3% of encounters in 2006 up to 30% by 2017. Timpone and colleagues estimated excess charges for this imaging at $8,670,832 in 2017 alone.
There is limited diagnostic value in using CT to examine the brain of patients suffering a transient ischemic attack. Yet researchers found that half of the top-10 most common neuroimaging combinations contained both CT and MRI scans (various guidelines favor magnetic resonance as the initial assessment tool).
“The reasons for such widespread use of CT brain imaging at facilities with access to MRI are unclear and could be secondary to lack of provider familiarity with guidelines,” the authors noted. “Alternatively, CT use in this setting may reflect lack of clinical confidence in the presumptive diagnosis or simply a judgment call to start with the cheap, commonly used and accessible CT examination while awaiting availability of MRI. Regardless, the likely overuse of noncontrast brain CT imaging has major consequences in terms both of cost and radiation exposure. As such, scrutinizing its use in this setting across EDs in the United States is recommended.”
You can read much more about their findings in the Journal of the American College of Radiology here.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.