Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction

In June 2016, the American College of Emergency Physicians (ACEP) Emergency Quality Network began its Reduce Avoidable Imaging Initiative , designed to “reduce testing and imaging with low risk patients through the implementation of Choosing Wisely r ecommendations”. However, it is unknown whether New England Emergency Departments (EDs) have already implemented evidence-based interventions to improve adherence to ACEP Choosing Wisely recommendations related to imaging after their initial release in 2013.  Our objective was to determine this, as well as whether provider-specific audit-and-feedback for imaging had been implemented in these EDs.

Methods

This survey study was exempt from Institutional Review Board review. In 2015, we mailed surveys to 195 hospital-affiliated EDs in all six New England states to determine whether they had implemented Choosing Wisely -focused interventions in 2014. Initial mailings included cover letters denoting the endorsement of each state’s ACEP chapter, and were followed-up twice with repeat mailings to non-responders. Data analysis included descriptive statistics and a comparison of state differences using Fisher’s exact test.

Results

A total of 169/195 (87%) of New England EDs responded, with all individual state response rates >80%. Overall, 101 (60%) of responding EDs had implemented an intervention for at least one Choosing Wisely imaging scenario; 57% reported implementing a specific guideline/policy/clinical pathway, 40% had implemented provider-specific audit-and-feedback, and 28% reported implementing a computerized decision support system. The most common interventions were for chest CT in patients at low-risk of pulmonary embolism (47% of EDs) and head CT in patients with minor trauma (45% of EDs). In addition, 40% of EDs had implemented provider-specific audit-and-feedback, without significant interstate variation (range: 29-55%).

Conclusion

One year after release of the ACEP Choosing Wisely recommendations, most New England EDs had a guideline/policy/clinical pathway related to at least one of the recommendations. However, only a minority were using provider-specific audit-and-feedback or computerized decision support. Few EDs have embraced the opportunity to implement the multiple evidence-based interventions likely to advance the national goals of improving patient-centered and resource-efficient care.