Application of ACR appropriateness criteria in ER could save billions

Emergency room physicians could save billions of dollars annually and spare their patients from unnecessary radiation exposure by adopting American College of Radiology appropriateness criteria to guide the use of CT and computed radiography for trauma patients, according to a study reported Monday.

Dr. Jonathan Hadley, a radiology resident at Eastern Virginia Medical School in Virginia Beach, found that CT and CR were routinely prescribed for 200 trauma patients enrolled in the study. Imaging utilization was nearly identical for all 200, even though 35% of the patients presented with no radiographically identifiable injuries, 17% had bumps and bruises, and only 48% suffered injuries serious enough to require hospitalization.

The 200 patients received a total of 660 CT exams and 429 CR procedures in the first three hours after arriving at the medical school's Level I trauma center. They generated $837,028 of imaging-related charges, or $4953 per patient, according to Hadley. In the process, each patient received an estimated whole-body exposure of 16 mSv of radiation.

The story would have been quite different if ACR appropriateness criteria had governed how imaging was prescribed, Hadley said. Compliance with those guidelines would have cut imaging costs by $300,000, and radiation exposure would have dropped to an average of 7 mSv. In reality, the savings would have been about five times less - about $60,000 - if Hadley had used actual insurance payable figures rather than charges for his standard.

In the question and answer session, he had difficulty answering whether chest x-rays should be routinely performed on apparently asymptomatic trauma patients to rule out pneumothorax.

Still, the difference translates into big numbers when applied to the nine million patients who appear in emergency rooms in the U.S. after accidents every year. ER compliance with the ACR appropriateness criteria would save $17 billion on imaging annually and would ultimately reduce the number of deaths associated with radiation-induced cancer by at least 2500 annually, he said.

"If you are going to image every patient who comes through the door, there is going to be a tremendous cost, both financially and in terms of unnecessary radiation exposure to those patients," Hadley said.