Better Solutions for Healthcare

Academic Emergency Medicine: Emergency Physician Perceptions of Medically Unnecessary Advanced Diagnostic Imaging

By Hemal K. Kanzaria, Jerome R. Hoffman, Marc A. Probst, John P. Caloyeras, Sandra H. Berry, Robert H. Brook

March 23, 2015

The objective was to determine emergency physician (EP) perceptions regarding 1) the extent to which they order medically unnecessary advanced diagnostic imaging, 2) factors that contribute to this behavior, and 3) proposed solutions for curbing this practice.


As part of a larger study to engage physicians in the delivery of high‐value health care, two multispecialty focus groups were conducted to explore the topic of decision‐making around resource utilization, after which qualitative analysis was used to generate survey questions. The survey was extensively pilot‐tested and refined for emergency medicine (EM) to focus on advanced diagnostic imaging (i.e., computed tomography [CT] or magnetic resonance imaging [MRI]). The survey was then administered to a national, purposive sample of EPs and EM trainees. Simple descriptive statistics to summarize physician responses are presented.


In this study, 478 EPs were approached, of whom 435 (91%) completed the survey; 68% of respondents were board‐certified, and roughly half worked in academic emergency departments (EDs). Over 85% of respondents believe too many diagnostic tests are ordered in their own EDs, and 97% said at least some (mean = 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. Solutions most commonly felt to be “extremely” or “very” helpful for reducing unnecessary imaging included malpractice reform (79%), increased patient involvement through education (70%) and shared decision‐making (56%), feedback to physicians on test‐ordering metrics (55%), and improved education of physicians on diagnostic testing (50%).


Overordering of advanced imaging may be a systemic problem, as many EPs believe a substantial proportion of such studies, including some they personally order, are medically unnecessary. Respondents cited multiple complex factors with several potential high‐yield solutions that must be addressed simultaneously to curb overimaging.

While the exact contribution of emergency care to U.S. national health expenditures remains controversial,15 emergency medicine (EM) is one of the high‐cost clinical settings far exceeding its sustainable growth rate target.6 Within EM there is significant variation in test‐ordering rates,710 and there has been a tremendous increase in utilization of advanced imaging despite little evidence to suggest associated improvement in patient outcomes.1115 The etiology of this increase is likely multifactorial and may include malpractice fear,1617 desire for diagnostic certainty,18 lack of or inconsistent clinical decision instruments,1820poor adoption of such decision instruments,2122 inadequate training in evidenced‐based medicine,2324 slow knowledge translation,25 perverse financial incentives,26 requests of consulting and referring physicians,2728 and increased practice intensity and overall complexity of emergency care.2829Regardless of etiology, there has been a strong push within EM to counter this behavior to provide high‐value, cost‐conscious care.1530

Despite the current nationwide effort to improve value in health care, viewpoints of frontline practicing clinicians on how to achieve better health and decreased costs remain largely unknown.31 Most physicians agree that they should take a greater role in reducing unnecessary tests,32 but little is known about the extent to which the typical emergency physician (EP) believes unnecessary diagnostic testing occurs in his or her practice setting or what solutions, if any, she or he feels would help mitigate this practice. Such information is crucial to achieving high‐value care and may be especially helpful in light of the upcoming 2015 Academic Emergency Medicine (AEM) consensus conference on diagnostic imaging.

We aimed to determine EP perceptions regarding 1) the extent to which they and their colleagues order medically unnecessary advanced diagnostic imaging, 2) factors that contribute most to this behavior, and 3) solutions that would be most effective at curbing this practice.


Study Design and Population

This was a cross‐sectional survey study, approved by the RAND Corporation Institutional Review Board (IRB). The final survey was administered to a nationally distributed, purposive sample of EPs recruited at four EM conferences and 15 distinct ED group meetings (faculty meetings, residency conferences, and community ED departmental meetings) between March and August 2013. The initial sampling approach was based on convenience, in that the investigators reached out to gain the permission of academic ED leaders in California with whom they were familiar. This was followed by a purposive sampling approach to recruit both community EPs and non‐California EPs. Leaders of community EDs in California, as well as of EDs in other parts of the country, with whom the investigators had some familiarity, were approached for permission to administer the survey. The four conferences were selected in a similar fashion, to provide a geographic balance of academic and community providers. Conference planning committees of both academic and continuing medical education conferences were contacted about the study; all conferences took place in California, but had attendees from throughout the country. Physicians practicing clinically in U.S. EDs, including those training in U.S. Accreditation Council for Graduate Medical Education–approved EM residency programs, were eligible for participation.

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