A “Top Five” list for emergency medicine: a policy and research agenda for stewardship to improve the value of emergency care

In 2010, Dr. Howard Brody wrote:

“the best rebuttal to the antireform argument that all efforts to control medical costs amount to the ‘government getting between you and your doctor’ is to have physicians, not ‘government,’ take the lead in identifying the waste to be eliminated. Mark Twain said, ‘Always do right. This will gratify some people and astonish the rest.’ Today, meaningful health care reform seems to be in danger of taking a back seat to special-interest pleading and partisan squabbling. If physicians seized the moral high ground, we just might astonish enough other people to change the entire reform debate for the better.”

Dr. Brody made an argument for specialty societies to take the lead and develop a list of tests or procedures that are commonly ordered but according to current evidence do not provide meaningful benefit. Many specialty societies joined the Choosing Wisely Campaign and have released their “Top 5” list but ACEP was notably absent from this movement.

We discussed ACEP’s absence from this list at our last advocacy meeting and unanimously agreed that Emergency Medicine should be part of the Choosing Wisely Campaign. Fresh off the heels of this discussion we discovered that ACEP had reversed their decision. They are now a partner in the campaign and plan to reveal their list of “top 5” tests or procedures that should be questioned or discussed and not just routinely ordered.

An article, just released, in the American Journal of Emergency Medicine establishes the case for why it is important for emergency physicians to be stewards of our available resources and to take the lead in establishing what areas of care should be examined for opportunities to reduce costs.

In the article “A ‘Top Five’ list for emergency medicine: a policy and research agenda for stewardship to improve the value of emergency care,” Drs. Venkatesh and Schuur discuss their recommendations for an approach to developing this top 5 list and the path forward after development of this list.

The authors begin by pointing out that if we as emergency physicians do not take the lead in being stewards of society’s resources and taking responsibility for health care costs, private insurers and government regulators will certainly fill that void and impose policies on the specialty. Furthermore, they argue that we have an ethical obligation to address the cost of care in our departments and that we as emergency medicine experts should define where we can limit testing and in the process demonstrate the value of emergency care.

The first step is to identify overuse. What are the tests, treatments, and disposition decisions that don’t change the care we provide? For example, 37% of all ED patients have a CBC drawn during their ED visit with little evidence that this test affects care. The authors argue that instead of actually doctoring which they say is “emphatic listening, physician examination, and clear communication,” we are too frequently using technology as a crutch. Other areas of overuse that could be targeted were identified. These include CT imaging which has seen a 330% increase in use since 1996 with no increase in diagnostic yield, antibiotics for upper respiratory infections and bronchitis, and IV fluids and medications. A recent study that has been accepted for publication showed that 50% of IVs inserted in an ED were unused.

Another issue the authors took up was the ability of the ED to serve as a definitive site of care. Interestingly, only 6% of patients are discharged without a recommendation for planned follow-up when there is no evidence that the majority of these follow up visits are needed. Most conditions seen in the ED are self-limited and can be treated as such. We as emergency physicians can ease the burden of a significant portion of primary care usage by providing complete diagnosis, treatment and education for conditions that don’t require follow up care.

The authors next addressed barriers to emergency physicians participating in cost reduction. A common cited reason for over-testing is legal concerns, however there is no good evidence that additional testing, or “defensive medicine” provides any medico-legal protections. The authors acknowledge that many hospitals may put pressure on physicians to maintain admissions and a certain level of testing as this is a major contributor to revenue. In the end, emergency physicians should advocate for a patient-centered model of care and a payment system that rewards patient-oriented outcomes and reducing health care spending as opposed to continuing the status quo.

The answers to many of the issues raised may not yet be known and more research needs to be done. However, the creation of a top five list will also help to stimulate research priorities and will likely lead to many more identified opportunities to reduce health care costs while improving emergency care.

It is becoming more clear that if we do not lead the effort to identify areas of overuse within our specialty others will step in and do it for us. It is likely not in our best interest or our patients to have these changes imposed upon us by others whose interests and expertise are different from ours. This article provides a good framework for identifying our “top 5” list and is something we all should read and consider as we try to provide the best care we can for our patients.

For more information, check out the linked papers in the resource section!

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