23 February 2016

CT Utilization in the Emergency Department: Improving Outcomes and Reducing Costs

Diagnostic imaging technology has made enormous strides over the past 20 years, helping medical professionals save thousands of lives by detecting disease earlier and more accurately. When imaging technology is implemented poorly, however, it can do more harm than good. Modern medical imaging methods, in general – and CT scans, in particular – deliver radiation doses that are orders of magnitude higher than conventional X-rays, which means that their benefits come with additional risk (including cancer). When these risks and benefits are not managed properly, the technology can actually have a net negative effect on overall population health and facility operating costs.

The United States is notorious for its overuse of healthcare resources: it's estimated that more than 30 percent of total U.S. healthcare spend is wasted due to overutilization. Studies have shown that the U.S. performs more than twice as many CT scans per capita as other developed nations, so the overuse rate for that procedure is likely even higher.

One of the keys to solving this problem is helping ED physicians know exactly which symptoms merit the use of diagnostic imaging and which don't. Because EDs account for approximately 30 percent of all imaging ordered at most facilities, reducing the department's overutilization can make a major difference.

Strategies for Reducing Overutilization

This may seem like a simple problem to solve, but our research has found that the root causes of ED radiology overutilization are actually fairly nuanced. Take CT utilization as an example: data collected by the Sheridan company Radisphere found high variance in the CT utilization rate across the hospitals surveyed (from less than 20 percent to above 40 percent, with a national median of 28.5 percent). Most surprising, however, was that the variance within groups (i.e., at each hospital) was actually higher than the variance between groups. Rates for individual ED physicians at the same hospital often ranged from 10 percent to 50 percent (figure 1), a range nearly twice as large as the inter-hospital rate.

These data demonstrate that variation in CT utilization between hospitals is to a large degree a function of individual doctors' utilization rates, and solely based on differences in policy from hospital to hospital. For this reason, hospitals that are trying to reduce their total utilization need to start by establishing clear guidelines for ED physicians regarding the symptoms and conditions that warrant a CT scan.

Because opinions on this are likely to be highly variable, any set of guidelines that is instituted from the top down will likely see low compliance rates. To ensure adoption, management should invite ED doctors to directly participate in the design of the policy. One of best ways to do this is through a Kaizen event. Kaizen events get an entire ED team together to dissect a department process and analyze any opportunities for increased efficiency. All team members – from nursing staff to clinical leaders to the C-suite – are invited to speak up, identify problems and collaborate with the team to solve them.

The solutions identified by the Kaizen team are often more effective than those developed by the leadership team alone. Team members are also more compliant with the processes developed in the Kaizen, as they personally had a hand in designing them.

ED CT utilization is clearly a perfect candidate for this type of process improvement. Standardizing the process by helping the ED and radiology teams set clear guidelines for CT use would help reduce the U.S. overutilization rate, improving population health and saving money at the same time.

If you'd like to learn more about how Sheridan helps hospitals use Kaizen to analyze and improve hospital processes, click here. For more information on Radisphere and its research into hospital utilization of radiology resources,

Figure 1

CT Utilization in Emergency Departments is Highly Variable - [graph].