Improving Emergency Department Imaging Value in Gynecologic Cancer

From the 2019 HVPAA National Conference

Dr. Stuart Ostby (University of Alabama at Birmingham Hospital), Dr. Joel Evans (University of Alabama at Birmingham Hospital), Dr. James Booth (University of Alabama at Birmingham Hospital), Dr. Matthew Heimann (University of Alabama at Birmingham Hospital), Dr. John Straughn (University of Alabama at Birmingham Hospital), Dr. Patrick Siler (University of Alabama at Birmingham Hospital), Dr. Jarred Thomas (University of Alabama at Birmingham Hospital)

Background

Radiologic testing with computerized tomography (CT) imaging is a major contributor to patient financial burden. The role of imaging in oncology requires careful consideration of type, timing, and patient treatment goals.

Objective

To identify advanced imaging patterns of use in the ED and increase the value of CT imaging performed.

Methods

Baseline data was obtained between 4/1/2017 and 5/31/2018 with specific measures of ED length of stay (LOS), patient oncologic history, and CT imaging use. The appropriateness of imaging was reviewed by two abstractors. Prospective evaluation of a guideline recommending consultation prior to repeating CT imaging within 3 weeks of a prior same study was implemented and evaluated between 6/1/2018 and 3/31/2019.

Results

During the baseline period, there were 135 ED encounters for established gynecologic oncology patients leading to admission. The mean age was 60 years and most patients had recurrent cancer (n=97; 72%) on treatment (n=90; 66.7%). The majority received one or more CT studies in the ED (n=97; 72%), with the majority (57%) deemed low value upon review. Prospective intervention data included 83 unique ED encounters with a 95% admission rate. Average patient age was 60 years, and most had recurrent cancer (n=51; 73%) on treatment (n=50; 71%). The baseline rate of 1 or more CT imaging studies by encounter was 78% compared to 46% following intervention. Imaging guidelines prevented imaging in 24 (29%) encounters. During the intervention period, nearly all patients were subsequently admitted (n=79; 95%). No identified harms or adverse patient events were observed in the group with imaging deferred. Respective mean ED LOS before and after the intervention was similar (8.5 versus 7.8 hours).

Conclusions

An imaging guideline for established gynecologic oncology cancer patients presenting to the ED reduced the rate of CT imaging use in 1 of 3 patient encounters.

Clinical Implications

Multispecialty collaboration and use of a shared approach for radiologic testing amongst patients with gynecologic cancers reduced the rate of CT utilization and serves as an extension of direct admission pathways.

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