Case 1: 29 year-old male with PMHx significant for Obesity who presents to the ED with complaints of fever, chills, generalized muscle aches, shortness of breath and a nonproductive cough. States symptoms have been present for approximately 5 days. Vitals: BP: 138/72 HR: 107 SpO2: 88% on 10 LPM RR: 38 Temp: 38.90 PMHx: Obesity Ht: 5’7” Wt: 153 kg

1. OCTOBER 26-29, 2020
Imaging, Overtesting, and Overuse: Just How Dangerous Is It?

2. @JeremyFaust

3. Conflicts
None

4. Modern medicine…
Over testing
Overuse
Emergency medicine is not immune

5. Problems with over testing
Expensive
Time-consuming
Poor use of resources
More is not better

6. But is overuse dangerous?
🤔

7. How big of a problem is it?
🤔

8. How big of a problem is it?

9. How big of a problem is it?
$158–$226 billion
wasted (2011)
Berwick DM, Hackbarth AD. Eliminating waste in US health
care. JAMA2012;307:1513–6.

10. Ann Intern Med. 2013 Jan 1; 158(1): 27–34.
Is more care better care?

11. Who is at fault?

12. Who is at fault?
Academic Emergency Medicine, Volume: 22, Issue: 4, Pages: 390-398, First published: 23 March 2015, DOI: (10.1111/acem.12625)

13. Who is at fault?
Academic Emergency Medicine, Volume: 22, Issue: 4, Pages: 390-398, First published: 23 March 2015, DOI: (10.1111/acem.12625)
ME
Y’ALL

14. How bad is it really?

15. How bad is it really?
1. CT scans.

16. BrennerDJ, Hall EJ. NEngl JMed 2007;357:2277-2284.

17. BrennerDJ, Hall EJ. NEngl JMed 2007;357:2277-2284.
1 : 1333

18. BrennerDJ, Hall EJ. NEngl JMed 2007;357:2277-2284.

19. BrennerDJ, Hall EJ. NEngl JMed 2007;357:2277-2284.
1 : 715

20. Lancet 2012; 380: 499–505

21. Lancet 2012; 380: 499–505
Of 10,000 people age 0 to 20 CT scanned
Leukemia (1 scan): 0.83 excess cases
Brain tumors (2-3 scans): 0.32 excess cases

22. Retrospective cohort study: 178,604 children
3x risk of
Leukemia for cumulative doses ~50 mGy
Brain cancer for ~ 60 mGy

23. Absolute vs relative risk: 3x small = still small!
1 excess leukemia and 1 excess brain tumor per
10,000 in first 10 yrs after pediatric head CT

24. BEIR-VII Lifetime Attributable Risk (LAR)
of radiation-induced cancer above baseline
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
0 10 20 30 40 50 60 70 80
Age at Exposure
LAR
(%
per
100
mSv) Female Cancer Incidence
Male Cancer Incidence
Sodickson, Baeyens, Prevedello, et. al. RecurrentCT, Cumulative Radiation Exposure, and Associated Radiation-Induced Cancer Risk from CT of Adults, Radiology. 2009;251(1)

25. Who are we worried about?
31,462 patients
33% > 5 exams
5% > 22 exams
1% > 38 exams
Mean 6.1 exams
Max 132 exams
Sodickson, Baeyens, Prevedello, et. al. RecurrentCT, Cumulative Radiation Exposure, and Associated Radiation-Induced Cancer Risk from CT of Adults, Radiology. 2009;251(1)
asodickson@bwh.harvard.edu

26. Sodickson, Baeyens, Prevedello, et. al. RecurrentCT, Cumulative Radiation Exposure, and Associated Radiation-Induced Cancer Risk from CT of Adults, Radiology. 2009;251(1)
Incremental risks vs benefits (indications)
asodickson@bwh.harvard.edu

27. Sodickson, Baeyens, Prevedello, et. al. RecurrentCT, Cumulative Radiation Exposure, and Associated Radiation-Induced Cancer Risk from CT of Adults, Radiology. 2009;251(1)
Incremental risks vs benefits (indications)
asodickson@bwh.harvard.edu
Patient FP - Cumulative Exposure and LAR
at 1 X, 1/2 X, 1/4 X Projected CT Rates
0
250
500
750
1000
1250
1500
1750
2000
2250
2500
2750
3000
3250
3500
3750
4000
25 30 35 40 45 50 55 60 65 70 75 80
Age
Cumulative
Exposure
(mSv)
0
5
10
15
20
25
%
Lifetime
Attributable
Risk
(LAR)
above
baseline

28. Cancer?
No one will trace it back to me.

29. How bad is it really?
2. We hurt kidneys

30. Do we hurt kidneys?

31. Do we hurt kidneys?
Contrast CT scan à acute kidney injury (AKI)
contrast is
associated
with AKI
contrast not
associated
with AKI
Aycock RD et al. Acute kidney injury after computed tomography: A meta-analysis. Ann Emerg Med 2017 Aug

32. Do we hurt kidneys?
Contrast CT scan à renal replacement therary
(dialysis or similar)
contrast is
associated
with RRT
contrast not
associated
with RRT
Aycock RD et al. Acute kidney injury after computed tomography: A meta-analysis. Ann Emerg Med 2017 Aug

33. Do we hurt kidneys?
Contrast CT scan à death
contrast is
associated
with death
contrast not
associated
with death
Aycock RD et al. Acute kidney injury after computed tomography: A meta-analysis. Ann Emerg Med 2017 Aug

34. Do we hurt kidneys?
Contrast CT scan à death
contrast is
associated
with death
contrast not
associated
with death
Aycock RD et al. Acute kidney injury after computed tomography: A meta-analysis. Ann Emerg Med 2017 Aug

35. What’s the bane of our existence?

36. Incidentalomas

37. Is point of care
ultrasound the answer?

38. Is point of care
ultrasound the answer?
A. Tewari et al. / Canadian Association of Radiologists Journal 66 (2015) 153e157

39. Ultrasound incidentalomas
A. Tewari et al. / Canadian Association of Radiologists Journal 66 (2015) 153e157

40. How bad is it really?
3. We bankrupt the country.

42. Assumption:
Spending less money saves money

43. Assumption:
Spending less money saves money

44. Assumption:
Spending less money saves money
“I am a good person.”
“I am a good doctor.”
“I am doing society a favor.”

45. What really happens?

46. What really happens?

47. What really happens?

48. ED spending (index visit):
Downstream care spending:

49. Can we even change?

50. Why do we over-test?
Academic Emergency Medicine, Volume: 22, Issue: 4, Pages: 390-398, First published: 23 March 2015, DOI: (10.1111/acem.12625)

51. What do we think would reduce
over testing?
Academic Emergency Medicine, Volume: 22, Issue: 4, Pages: 390-398, First published: 23 March 2015, DOI: (10.1111/acem.12625)

52. Does malpractice reform help?
Waxman DAetal. NEngl JMed 2014;371:1518-1525.

53. Waxman DAetal. NEngl JMed 2014;371:1518-1525.
Charges ($)
Does malpractice reform help?

54. Waxman DAetal. NEngl JMed 2014;371:1518-1525.
Does malpractice reform help?

55. Waxman DAetal. NEngl JMed 2014;371:1518-1525.
CT imaging
Does malpractice reform help?

56. Waxman DAetal. NEngl JMed 2014;371:1518-1525.
Does malpractice reform help?

57. Waxman DAetal. NEngl JMed 2014;371:1518-1525.
ADMISSIONS
Does malpractice reform help?

58. Waxman DAetal. NEngl JMed 2014;371:1518-1525.
Does malpractice reform help?

59. Does anything help?

60. Does anything help?

61. Does anything help?

62. Does anything help?

63. Does anything help?

64. Uptake?

65. Uptake?

66. Uptake?

67. In review
More care ≠ better
49.999% of us are worse than average
CT scans add up. Not your fault.

68. In review
Contrast not so bad in our setting.
Incidentalomas and ultrasound.
Spending less money may be costly.
Malpractice reform only a little helpful
Culture matters.