Fear of Litigation, Missed Diagnoses Spur Overuse of Imaging in EDs

October 7th, 2016

LOS ANGELES – When emergency physicians order advanced imaging, they may suspect the study is medically unnecessary some of the time but are motivated by fear of missing a diagnosis or being sued, according to a new study.

The report, published recently in the journal Academic Emergency Medicine, points out, “Over-ordering of advanced imaging may be a systemic problem, as many [emergency physicians] believe a substantial proportion of such studies, including some they personally order, are medically unnecessary.”

Solving the problem, according to the study led by researchers from the Robert Wood Johnson Foundation Clinical Scholars Program, the Los Angeles Veterans Affairs Healthcare System and the University of California Los Angeles, will require dealing with “multiple complex factors” that “must be addressed simultaneously to curb over-imaging.”

In initiating the study, researchers sought to determine emergency physician (EP) perceptions regarding the extent to which they order medically unnecessary advanced diagnostic imaging, factors that contribute to the behavior, and proposed solutions for curbing the practice.

As part of a larger study to engage physicians in the delivery of high-value health care, the study team conducted two focus groups to explore the topic of decision-making around resource utilization and then used qualitative analysis to generate survey questions. The survey, which was extensively pilot-tested, focused on advanced diagnostic imaging, i.e., computed tomography [CT] or magnetic resonance imaging [MRI].

With 478 emergency physicians approached, 435 (91%) completed the survey – 68% of the respondents were board-certified, and roughly half worked in academic emergency departments.

More than 85% of respondents said they believe too many diagnostic tests are ordered in their own EDs, and 97% said at least some – an average of 22% – of the advanced imaging studies they personally order are medically unnecessary.

“The main perceived contributors were fear of missing a low-probability diagnosis and fear of litigation,” according to the authors.

“Extremely” or “very” helpful possible solutions, according to survey respondents, include:

• malpractice reform (79%),
• increased patient involvement through education (70%),
• shared decision-making (56%),
• feedback to physicians on test-ordering metrics (55%), and
• improved education of physicians on diagnostic testing (50%).