Are MRI and CT of brain being overused for diagnosing dizziness?
Minneapolis: In cases of dizziness, MRI and CT of the brain most likely are being overused both in patients presenting in the emergency department and those presenting in outpatient clinics, says a recent study. The study was published in the journal JAMA Otolaryngology-Head & Neck Surgery on April 7, 2022.
"The use of neuroimaging for dizziness is prevalent across settings," Meredith E. Adams, Department of Otolaryngology–Head and Neck Surgery, University of Minnesota, Minneapolis, and colleagues wrote in their study. "To discouarge guideline-discordant use of CT scans, account for the effects of price transparency, and advocate for judicious MRI use (particularly in ambulatory settings), interventions to optimize neuroimaging use must occur early in the patient care journey."
Excess use of costly neuroimaging technology is tied to low-value care for the prevalent symptom of dizziness. Although initiaietives for quality improvement have focused on the overuse of computed tomography (CT) scans in emergency departments (EDs), most dizziness patients present to outpatient clinics. To inform practice and policy, arises a need for a a comprehensive understanding of the uses and costs of neuroimaging across settings and episodes of care.
The study was conducted with an objective to characterize neuroimaging use, timing, and spending as well as factors associated with imaging acquisition within 6 months of presentation for dizziness in outpatient vs ED settings.
For this purpose, the researchers conducted a cross-sectional study of commercial and Medicare Advantage claims for 805 454 adults (≥18 years of age) with new diagnoses of dizziness between January 1, 2006 and December 31, 2015.
The researchers measured neuroimaging (CT scan, angiography, magnetic resonance imaging [MRI], and ultrasonography) use and total spending on neuroimaging.
The study included a total of 805 454 individuals with dizziness (502 055 women [62%]; median age, 52 years).
Based on the study, the researchers reported the following findings:
- 20% underwent neuroimaging within 6 months of presentation (65 738 of 185 338 [36%] presented to EDs and 91 231 of 620 116 [15%] presented to outpatient clinics).
- The median time to neuroimaging was 0 days after ED presentation and 10 days after outpatient presentation.
- Neuroimaging was independently associated with advanced age, comorbidity, race and ethnicity, ED presentation, and outpatient clinician specialty.
- Across sites, a head CT scan was the most used test on presentation date (92% of tests [46 852 of 51 022]).
- Within 6 months of presentation, a head CT scan was the most used test (47% of all tests [177 949 of 376 149]), followed by brain MRI (25% [93 130 of 376 149]), cerebrovascular ultrasonography (15% [56 175 of 376 149]), and magnetic resonance angiography (9% [34 026 of 376 149]).
- Of $88 646 047.03 in total neuroimaging spending, MRI accounted for 70%, CT scans for 19%, and ultrasonography for 11%.
- Per-test median spending ranged from $68.97 (CT scan of the head) to $319.63 (MRI of the brain) among commercially insured individuals and $43.21 (CT scan of the head) to $362.02 (MRI of the orbit, face, and neck) among Medicare Advantage beneficiaries.
Although neuroimaging for dizziness optimization has focused on the overuse of head CT scans in the ED, there is a need for intervention to promote guideline-concordant use of MRI and CT in outpatient settings, where most dizziness presentations occur, the authors concluded.
Adams ME, Karaca-Mandic P, Marmor S. Use of Neuroimaging for Patients With Dizziness Who Present to Outpatient Clinics vs Emergency Departments in the US. JAMA Otolaryngol Head Neck Surg. Published online April 07, 2022. doi:10.1001/jamaoto.2022.0329
KEYWORDS: JAMA, dizziness, neuroimaging, mri, ct, outpatient clinics, emergency department, magnetic resonance imaging, computed tomography, Meredith E Adams, imaging