The use of unnecessary neuroimaging for patients suffering from dizziness is prevalent in outpatient healthcare settings, according to a new analysis published Thursday.
Quality improvement efforts have sought to address such low-value diagnostic testing in the emergency department. However, oftentimes patients present with this concern in ambulatory care clinics, University of Minnesota experts wrote in JAMA Otolaryngology-Head Neck Surgery.
To better understand the scope of the problem, scientists combed through Medicare Advantage claims from more than 805,000 individuals with new diagnoses of dizziness between 2006-2015. About 20% underwent neuroimaging within six months of the initial visit and 26% of that group received two ore more scans.
By setting, 15% of outpatient visitors received unnecessary brain imaging compared to 35% of ED subjects.
“The findings of this cross-sectional study suggest that use of neuroimaging for dizziness is prevalent across settings,” Meredith E. Adams, MD, with the Minneapolis-based institution’s department of otolaryngology, and co-authors concluded. “Interventions to optimize the use of neuroimaging must occur early in the patient care journey to discourage guideline-discordant use of CT scans, advocate for judicious MRI use (particularly in ambulatory settings), and account for the effects of price transparency.”
For their study, Adams et al. utilized claims from the OptumLabs Data Warehouse, which includes a diverse mix of patients from geographical regions across the U.S. Individuals ranged in age from 18 t0 87, with a median of 52 years old. Mirroring similar findings in previous studies, providers overused CT in the emergency department (25% at presentation, 32% at the six-month mark). The modality also far outpaced MRI in the ED (3% on presentation and 4% half a year later). Meanwhile, imaging was less frequent in the outpatient setting and typically occurred well after initial presentation, experts noted. CT and MRI rates were more similar among ambulatory patients vs. the ED.
Neuroimaging was associated with higher patient age, comorbidities, race and ethnicity, ED presentation, and the outpatient providers’ specialty. Across all sites, CT was the most used test on the initial presentation date (92%). Same for six months afterward with CT at 47%, followed by brain MRI (25%), cerebrovascular ultrasound (15%), and magnetic resonance angiography (9%). Out of a total of $88 million in neuroimaging spending across the study population, MRI held the largest share (70%), followed by CT (19%) and ultrasound (11%).
In a corresponding editorial, experts noted that MRI is far more accurate for diagnosing strokes. But shifting these patient presentations to the modality is likely to “balloon costs, in spite of plummeting reimbursements.
“We need better bedside diagnoses in frontline care settings (in both EDs and outpatient clinics) that can drive more appropriate use of neuroimaging, mostly by MRI,” experts wrote. “We know this is possible using modern approaches to diagnosing dizziness that emphasize timing, triggers and targeted examinations.”
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.