Role of emergency medicine physicians in US performed in patients in the emergency department: how substantial is their participation?

A consensus list of ultrasound competencies for graduating emergency medicine residents

OBJECTIVES

Emergency ultrasound (EUS) is a critical component of emergency medicine (EM) resident education. Currently, there is no consensus list of competencies for EUS training, and graduating residents have varying levels of skill and comfort. The objective of this study was to define a widely accepted comprehensive list of EUS competencies for graduating EM residents through a modified Delphi method.

METHODS

We developed a list of EUS applications through a comprehensive literature search, the American College of Emergency Physicians list of core EUS benchmarks, and the Council of Emergency Medicine Residency-Academy of Emergency Ultrasound consensus document. We assembled a multi-institutional expert panel including 15 faculty members from diverse practice environments and geographical regions. The panel voted on the list of competencies through two rounds of a modified Delphi process using a modified Likert scale (1 = not at all important, 5 = very important) to determine levels of agreement for each application-with revisions occurring between the two rounds. High agreement for consensus was set at >80%.

RESULTS

Fifteen of 15 panelists completed the first-round survey (100%) that included 359 topics related to EUS. After the first round, 195 applications achieved high agreement, four applications achieved medium agreement, and 164 applications achieved low agreement. After the discussion, we removed three questions and added 13 questions. Fifteen of 15 panelists completed the second round of the survey (100%) with 209 of the 369 applications achieving consensus.

CONCLUSION

Our final list represents expert opinion on EUS competencies for graduating EM residents. We hope to use this consensus list to implement a more consistent EUS curriculum for graduating EM residents and to standardize EUS training across EM residency programs.

National Trends in Imaging Rates for Eye-Related Emergency Department Visits in the United States

PURPOSE

To identify nationwide trends and factors associated with advanced imaging (computed tomography [CT] and magnetic resonance imaging [MRI]) use for eye-related emergency department (ED) visits.

DESIGN

Retrospective, trend study.

METHODS

Setting: National Hospital Ambulatory Medical Care Survey 2007-2015.

PATIENT POPULATION

Eye-related ED patients who underwent CT or MRI.

MAIN OUTCOME MEASURE(S)

Population-based CT/MR imaging rates and independent factors associated with imaging.

RESULTS

An estimated 7 million eye-related ED visits occurred between 2007 and 2015. Adjusted for annual eye-related ED visits, the rate of imaging use rose 94%, from 121.7 per 1,000 eye-related ED visits in 2007 to 236.0 per 1,000 eye-related ED visits in 2015. Visual disturbances, contusion of the eye and/or adnexa, open globes and open wounds of ocular adnexa, diplopia, superficial corneal and/or conjunctival injuries, and orbital fractures accounted for 73.2% of all visits where imaging was performed. On multivariable analysis, older patients (odds ratio [OR] = 1.02, 95% confidence interval [CI] 1.01-1.03) and females (OR=2.07, 95% CI 1.18-3.63) were more likely to undergo imaging than younger patients and males. Imaging was also more likely to be performed for Medicare beneficiaries (OR=2.12, 95% CI 1.08-4.15) than for privately insured patients. Patients who were admitted to the hospital were 6 times more likely (OR=6.39, 95% CI 2.04-20.0) to undergo imaging than those who were not admitted.

CONCLUSIONS

Advanced imaging for eye-related ED visits has escalated at a higher rate than ED visits for eye complaints. Future studies to develop evidence-based algorithms for use of CT/MR imaging for eye complaints that can help balance benefits against financial costs and health risk are warranted.

Optimizing diagnostic imaging in the emergency department

While emergency diagnostic imaging use has increased significantly, there is a lack of evidence for corresponding improvements in patient outcomes. Optimizing emergency department (ED) diagnostic imaging has the potential to improve the quality, safety, and outcomes of ED patients, but to date, there have not been any coordinated efforts to further our evidence-based knowledge in this area. The objective of this article is to discuss six aspects of diagnostic imaging to provide background information on the underlying framework for the 2015 Academic Emergency Medicine consensus conference, "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The consensus conference aims to generate a high priority research agenda for emergency diagnostic imaging that will inform the design of future investigations. The six components herein will serve as the group topics for the conference: 1) patient-centered outcomes research; 2) clinical decision rules; 3) training, education, and competency; 4) knowledge translation and barriers to image optimization; 5) use of administrative data; and 6) comparative effectiveness research: alternatives to traditional CT use.

Do emergency medicine physicians perform ultrasound and conventional radiography in the emergency department? Recent trends from 1993 to 2001

PURPOSE

To examine trends in emergency medicine physicians' participation in diagnostic ultrasound and conventional radiography from 1993 to 2001.

METHODS AND MATERIALS

The nationwide Medicare Part B Physician/Supplier Procedure Summary Master Files for 1993 and 1996 through 2001 were examined to determine the total number of ultrasound and conventional radiography examinations performed in emergency departments, except for ophthalmic ultrasound and supervision or interpretation claims. Ultrasound examinations were categorized as general, vascular, breast, echocardiography, and obstetrical. Conventional x-ray examinations were categorized as chest, skeletal, abdomen, and gastrointestinal fluoroscopy. The total volume and overall share of the two modalities and nine aforementioned categories were calculated for each year for radiologists, emergency medicine physicians, other nonradiologists, and multispecialty groups using the Medicare provider and location-of-service codes.

RESULTS

The total volume of ultrasound examinations performed in emergency departments increased from 134,533 in 1993 to 355,889 in 2001 (+164.5%). Emergency medicine physicians performed 760 (0.6%) of the examinations in 1993 and 1160 (0.3%) in 2001. Radiologists performed 87,377 (64.9%) in 1993 and 257,479 (72.3%) in 2001, other nonradiologists (primarily cardiologists performing echocardiography and vascular surgeons performing vascular ultrasound) performed 40,501 (30.1%) in 1993 and 76,649 (21.5%) in 2001, and multispecialty groups performed 5895 (4.4%) in 1993 and 20,601 (5.8%) in 2001. The total volume of conventional radiography examinations increased from 5,120,608 in 1993 to 8,054,771 (+57.3%) in 2001. Emergency medicine physicians performed 243,705 examinations (4.8%) in 1993 and 167,968 (2.1%) in 2001, radiologists performed 4,558,933 (89.0%) and 7,478,659 (92.8%), other nonradiologists performed 113,848 (2.2%) and 99,627 (1.2%), and multispecialty groups performed 204,122 (4.0%) and 308,517 (3.8%). The largest volume of examinations performed by radiologists and emergency medicine physicians in emergency departments in 2001 was in chest radiography, with radiologists performing 3,765,209 and emergency medicine physicians performing 98,851. The largest volume for other nonradiologists in emergency departments in 2001 was in echocardiography; they performed 53,943 of these examinations.

CONCLUSION

Emergency medicine physicians perform a very small percentage of all ultrasound and conventional x-ray examinations performed in emergency departments, with their share decreasing over the 8-year period. The fact that the participation of emergency medicine physicians in ultrasound imaging and conventional radiography in emergency departments is limited and has been decreasing makes their claim of substantial participation highly questionable.

Ultrasonography in community emergency departments in the United States: access to ultrasonography performed by consultants and status of emergency physician-performed ultrasonography

STUDY OBJECTIVE

Nearly all emergency medicine residency programs provide some training in emergency physician-performed ultrasonography, but the extent of emergency physician-performed ultrasonography in community emergency departments (EDs) is not known. We seek to determine the state of ultrasonography in community EDs in terms of access to ultrasonography by other specialists and performance of ultrasonography by emergency physicians.

METHODS

A 6-page survey that addressed access to ultrasonography performed by other specialists and emergency physician-performed ultrasonography was designed and pilot tested. A list of all US ED directors was obtained from the American College of Emergency Physicians. Twelve hundred of 5264 EDs were randomly selected to receive the anonymous survey, with responses tracked by separate postcard. There were 3 mailings from Fall 2003 to Spring 2004.

RESULTS

Overall response rate was 61% (684/1130). Respondents who self-reported as being academic with emergency medicine residents were excluded from further analysis (n=35). A sensitivity analysis (reported in parentheses) was performed on the key outcome question to adjust for response bias. As reported by ED directors, ultrasonography was available in the ED for use by emergency physicians at all times in 19% of EDs (12% to 28%), with an additional 15% (9% to 21%) reporting a machine available for use by emergency physicians in some capacity and 66% (51% to 80%) reporting that there was no access to a machine for emergency physician use. ED directors reported being requested or required to limit ultrasonography orders performed by radiology in 41% of EDs, with less timely access to radiology-performed ultrasonography in off hours. Of EDs with emergency physician-performed ultrasonography, the most common applications were Focused Assessment with Sonography for Trauma (FAST) examination (85%), code situation (72%), and check for pericardial effusion (67%). Of physicians performing ultrasonography, 16% stated they were currently requesting reimbursement (billing). The primary reason cited for not implementing emergency physician-performed ultrasonography was lack of emergency physician training. For the statement "emergency medicine residents now starting residency should be trained to perform and interpret focused bedside ultrasonography," 84% of ED directors agreed, 14% were neutral, and less than 2% disagreed.

CONCLUSION

Community ED directors continue to report barriers to obtaining ultrasonography from consultants, especially in off hours. Nineteen percent of community ED directors report having a machine available for emergency physician use at all times; however, two thirds of EDs report no access to ultrasonography for emergency physician use. A majority of community ED directors support residency training in emergency physician-performed ultrasonography.

Turf wars in radiology: Emergency department ultrasound and radiography

In recent years, emergency medicine physicians have made strenuous efforts to take over responsibility for interpreting and billing for ultrasound and conventional x-ray studies performed in emergency departments. This is a battle that radiologists have largely won. The authors explore some of the history of this controversy and the reasons why radiologists still control emergency department imaging.

Performance, training, quality assurance, and reimbursement of emergency physician-performed ultrasonography at academic medical centers

OBJECTIVE

To determine the current state of bedside emergency physician-performed ultrasonography in terms of prevalence, training, quality assurance, and reimbursement at emergency medicine residency programs.

METHODS

The link to a 10-question Web-based survey was e-mailed to ultrasound/residency directors at 122 emergency medicine residency programs in the United States.

RESULTS

The overall response rate was 84%. Ninety-two percent of programs reported 24-hour emergency physician-performed ultrasonography availability. Fifty-one percent of programs reported that a credentialing/privileging plan was in place at their hospital, and 71% of programs had a quality assurance/image review procedure in place. Emergency medicine specialty-specific guidelines of 150 ultrasonographic examinations and 40 hours of didactic instruction were met by 39% and 22% of residencies, respectively, although only 13.7% of programs were completing the 300 examinations recommended by the American Institute of Ultrasound in Medicine. Sixteen programs (16%) reported that they were currently billing for emergency physician-performed ultrasonography; of those not billing, 10 (12%) planned to bill within 1 year, and 32 (37%) planned to bill at some point in the future.

CONCLUSIONS

Performance and training in emergency physician-performed ultrasonography at academic medical centers continues to increase. The number of emergency medicine residency programs meeting specialty-specific guidelines has more than doubled in the last 4 years, but only a small number are meeting American Institute of Ultrasound in Medicine guidelines. Although only 16% of programs reported that they were currently billing for emergency physician-performed ultrasonography, most had plans to bill in the future.

Cardiovascular imaging: who does it and how important is it to the practice of radiology?

OBJECTIVE

Our research was conducted to ascertain the importance of noninvasive cardiovascular imaging to the practice of radiology and to determine what percentages of noninvasive cardiovascular imaging are performed by radiologists and by other types of physicians.

MATERIALS AND METHODS

Using the national 1998 Medicare Part B database, we reviewed all 460 procedure codes pertaining to noninvasive diagnostic imaging and identified 65 that were specifically related to the cardiovascular system. These 65 codes were grouped in five categories: cardiac MR imaging, MR angiography, cardiovascular nuclear medicine, echocardiography, and vascular sonography. For each code and category, we determined the nationwide examination volume, the utilization rate per 1,000 Medicare fee-for-service enrollees, Part B physician reimbursements, and the percentages of examinations performed by radiologists, cardiologists, surgeons, and other physicians.

RESULTS

During 1998, 19,244,001 noninvasive cardiovascular imaging studies were performed on Medicare enrollees, which accounted for 17.7% of all Medicare diagnostic imaging studies carried out that year and 33.6% of all Part B imaging-related reimbursements paid. The utilization rate for noninvasive cardiovascular imaging was 603 per 1,000 Medicare enrollees per year. Echocardiography alone accounted for 63.4% of these examinations. Radiologists conducted 16.7% of all noninvasive cardiovascular imaging, whereas cardiologists conducted 61.5%, surgeons 4.8%, and other physicians 16.9% of the examinations. The strong role of cardiologists was largely attributable to their dominance in echocardiography. Radiologists had a substantial role in all categories except echocardiography.

CONCLUSION

Noninvasive cardiovascular imaging represents an important component of the practice of radiology. Radiologists have substantial participation in all aspects of the field with the exception of echocardiography.