Choosing wisely in emergency medicine: Early results and insights from the ACEP emergency quality network (E-QUAL)

Abstract

Purpose: To characterize performance among ED sites participating in the Emergency Quality Network (E-QUAL) Avoidable Imaging Initiative for clinical targets on the American College of Emergency Physicians Choosing Wisely list. Methods: This was an observational study of quality improvement (QI) data collected from hospital-based ED sites in 2017–2018. Participating EDs reported imaging utilization rates (UR) and common QI practices for three Choosing Wisely targets: Atraumatic Low Back Pain, Syncope, or Minor Head Injury. Results: 305 ED sites participated in the initiative. Among all ED sites, the mean imaging UR for Atraumatic Low Back Pain was 34.7% (IQR 26.3%–42.6%) for XR, 19.1% (IQR 11.4%–24.9%) for CT, and 0.09% (IQR 0%–0.9%) for MRI. The mean CT UR for Syncope was 50.0% (IQR 38.0%–61.4%). The mean CT UR for Minor Head Injury was 72.6% (IQR 65.6%–81.7%). ED sites with sustained participation showed significant decreases in CT UR in 2017 compared to 2018 for Syncope (56.4% vs 48.0%; 95% CI: −12.7%, −4.1%) and Minor Head Injury (76.3% vs 72.1%; 95% CI: −7.3%, −1.1%). There was no significant change in imaging UR for Atraumatic Back Pain for XR (36.0% vs 33.3%; 95% CI: −5.9%, −0;5%), CT (20.1% vs 17.7%; 95% CI: −5.1%, −0.4%) or MRI (0.8% vs 0.7%, 95% CI: −0.4%, −0.3%). Conclusions: Early data from the E-QUAL Avoidable Imaging Initiative suggests QI interventions could potentially improve imaging stewardship and reduce low-value care. Further efforts to translate the Choosing Wisely recommendations into practice should promote data-driven benchmarking and learning collaboratives to achieve sustained practice improvement.