The E-QUAL Avoidable Imaging Workgroup developed and approved nine imaging utilization measures to translate the clinical practice statements of the ACEP Choosing Wisely list into proportional and quantifiable metrics for QI purposes. The primary outcome measure for this study was indication-specific imaging utilization rates based on E-QUAL measure definitions (see Appendix 3). 13 This initiative aims to establish national benchmarking data for imaging utilization using a large sample of hospital-based community EDs, disseminate common QI interventions, share best practices to reduce avoidable imaging, and report performance variation and improvement trends. To address these gaps, The American College of Emergency Physicians (ACEP) Emergency Quality Network (E-QUAL) created the Avoidable Imaging Initiative in 2016.
9– 11 Clinicians continue to be vulnerable to the “therapeutic illusion” of believing that their diagnostic tools are more effective than they actually are, resulting in unnecessary or costly care. 8 Finally, studies showed that while most ED physicians acknowledge overimaging as a problem, they are unaware of their own overutilization and continue to perform low value services. 6, 7 EDs that engaged in performance improvement initiatives to reduce imaging utilization also have few national benchmarks for comparison. While they showed promise in reducing potentially avoidable imaging within local contexts, efforts to identify and disseminate best practices have been limited and mostly confined to academic settings. These efforts are highly varied and include clinical pathways, computerized decision support tools, physician audit and feedback, and shared-decision making. Since the inception of Choosing Wisely, emergency departments (EDs) across the country have initiated quality improvement (QI) efforts to implement recommendations in concert with national “Top Five” lists. One large national study demonstrated a 330% increase in CT utilization in the ED between 19 without improving diagnostic yield, and a study of Medicare beneficiaries found that the low-value services targeted by the Choosing Wisely initiative may contribute over $8.5 billion a year to annual health care costs in the Medicare program alone. 2 These recommendations were based on research demonstrating the potential overuse of imaging for several indications despite evidence-based guidelines to direct practice. 1 Five of the ten items identified by ACEP were focused on the use of advanced imaging. By 2014, the American College of Emergency Physicians (ACEP) had published ten evidence-based Choosing Wisely recommendations to promote resource stewardship and reduce low-value care in the emergency department (ED).
The Choosing Wisely campaign was launched by the American Board of Internal Medicine Foundation in 2012 to promote physician stewardship of healthcare resources by encouraging specialty societies to develop “Top Five” lists of low-value care practices amenable to avoidance. Further efforts to translate the Choosing Wisely recommendations into practice should promote data-driven benchmarking and learning collaboratives to achieve sustained practice improvement. There was no significant change in imaging UR for Atraumatic Back Pain for XR (36.0% vs 33.3% 95% CI: -5.9%, -0 5%), CT (20.1% vs 17.7% 95% CI: -5.1%, -0.4%) or MRI (0.8% vs 0.7%, 95% CI: -0.4%, -0.3%).ConclusionsEarly data from the E-QUAL Avoidable Imaging Initiative suggests QI interventions could potentially improve imaging stewardship and reduce low-value care. ED sites with sustained participation showed significant decreases in CT UR in 2017 compared to 2018 for Syncope (56.4% vs 48.0% 95% CI: -12.7%, -4.1%) and Minor Head Injury (76.3% vs 72.1% 95% CI: -7.3%, -1.1%).
The mean CT UR for Minor Head Injury was 72.6% (IQR 65.6%-81.7%). Participating EDs reported imaging utilization rates (UR) and common QI practices for three Choosing Wisely targets: Atraumatic Low Back Pain, Syncope, or Minor Head Injury.Results305 ED sites participated in the initiative. PurposeTo characterize performance among ED sites participating in the Emergency Quality Network (E-QUAL) Avoidable Imaging Initiative for clinical targets on the American College of Emergency Physicians Choosing Wisely list.MethodsThis was an observational study of quality improvement (QI) data collected from hospital-based ED sites in 2017-2018.