How much unnecessary testing goes on in the ER?

Plenty, if you ask the people most familiar with the situation, the emergency physicians themselves.

According to a survey from Emergency Physicians Monthly , many tests performed in the ER are deemed unnecessary to good patient care. Here’s how doctors responded to the following question: “Given that in a typical shift of eight hours you see an average of two patients per hour (16 patients/shift), could you have eliminated any of the following tests and/or treatments without compromising the quality of care? If so, how many of each?”

How much unnecessary testing goes on in the ER?

As you can see, laboratory tests and CT scans comprised the greatest proportion of unnecessary tests. It’s been well-debated on this blog as to why, but one reason is that there’s a mentality that a wide net has to be cast, so that uncommon causes of a patient’s presentation aren’t missed.

The survey also found that non-economic caps are these physicians’ preferred choice of malpractice reform, with 84 percent of emergency physicians calling them a “non-negotiable part of health reform.” Politically, however, that’s unlikely to take hold.

What makes more sense is providing some sort of protection for doctors to adhere to evidence-based standards of care. If we can standardize the indications as to when specific tests are indicated, and reinforce them by linking them to malpractice protection, I think you’d see doctors taking less of a “shotgun” approach.

And when bending the cost curve is becoming a primary concern, that’s an important consideration. Especially when you consider that many ER physicians think they can save more than $500 per shift by removing unnecessary testing.

How much unnecessary testing goes on in the ER?

(via WhiteCoat’s Call Room)

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  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    “Plenty, if you ask the people most familiar with the situation, the emergency physicians themselves.”

    Imagine that! Asking the doctors themselves. What a concept!

  • Matt

    “The survey also found that non-economic caps are these physicians’ preferred choice of malpractice reform, with 84 percent of emergency physicians calling them a “non-negotiable part of health reform.” Politically, however, that’s unlikely to take hold.”

    It’s interesting to see physicians support caps, since it really makes no sense unless they believe some of their insurers savings will trickle down to them. It’s not really something that is really just, since they apply regardless of the merit of the case. It appears to be an impressive bit of marketing on the part of insurers that has caused physicians to be the face of the caps movement.

    And do those caps reduce those tests? We’ve had caps for 30 years – has it reduced the number of tests performed in those ERs in capped states? That would seem to be the best evidence of their efficacy in this situation. The fact that there are no studies supporting this would seem to confirm they don’t work to reduce “defensive medicine”.

  • SarahW

    Nothing is ever going to protect a doctor when he’s missed something he should have seen. In hindsight, that’s something a patient has to prove, and your guidelines might make it easier to excuse his failure as what is well within the tolerated management of the patient in the practice of medicice. I caution you however, it can’t save the doctor who misses what he could have seen if he had merely looked carefully at the patient’s history, examined the patient thoroughly, – acutally listened to the patient to draw out the “special circumstances” without controlling the conversation to the point the patient can’t tell you the information you need to judge properly.

    Because in hindsight, there is likely to be found something right there under your nose that would have informed your decision to test or not, which you missed. You did it wrong. You didn’t order an appropriate test and you “cheated” by not gathering enough information to use the little immunizing flowchart provided, correcty.

    Face another reality: imaging tests and others have replaced careful histories and careful exams. It’s really changed the practice of medicine and not just to CYA shotgun treat – but because it’s the new tool to “examine.”
    They are the patient interview.

    Immunity for making an avoidable mistake is not likely to result for these charts. And I think on the contrary it may inflame juries when they find out you used that chart that determined this patients negative fate, without having enough information to do so correctly.

  • http://thehappyhospitalist.blogspot.com Happy Hospitalist

    Sarah W “should have seen” can only be known after the fact. Some how connecting “should have seen” with negligence is at the root of our defensive medicine cost problem. Missing the diagnosis will always be a byproduct of the differential diagnosis, which will never be accurate with 100% certainty. When the missed diagnosis becomes a bad outcome, the issue is rarely gross negligence, but rather a by product of the unknowns of clinical medicine. By practicing medicine in the posssible, instead of the probable we spend, by my own estimation from what I see every day, 30% of our health care to defend ourselves against the unknown outcomes which is possible, but not likely probable. And something that is only known after the fact.

  • Doc Stone

    SarahW-I’m not really sure what your position is. Nobody is talking about liability protection for docs who don’t order testing after a shoddy history and physical, even if they follow guidelines. The idea is to protect docs who follow these guidelines after accounting for all relevant medical information (including a thorough H&P) and there’s still a bad outcome – yes, this is possible. Would you be against protection of a physician in this latter case?

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  • Michigan Trooper

    This article focuses in the right direction but needs more digging. $500 of unnecessary tests per shift seems economically inconsequential. When I started reading this article I was thinking $10 – $20K per day in unnecessary tests, referrals and screenings at our (pop. 12K) small town hospital ER.

  • http://www.patmosemergiclinic.com Robert Berry, MD

    If insured patients had to pay more of non-emergency care out of pocket, they would not use the ER and initiate the process of expensive care. ER docs don’t have a relationship with these patients and can’t bring them back the next day for rechecks. The patients should choose physicians with whom they have a personal relationship and whose conditions can be followed closely. And if the patients have to pay for the non-emergency testing as well, then economic principles would be introduced at the point of care. I should know – I have a full time cash-only practice and work a shift a week in the ER. My cash-only practice (and others like it) are the epitome of cost effective medicine.