How to Save One Billion Dollars a Year

Alan Desmond
August 21, 2013

Last week, we reviewed a recent story published by Johns Hopkins. The story summarizes an article that recently appeared in the July issue of Emergency Academic Medicine. This week, I want to discuss some new (at least to me) demographic information that was obtained as part of that article.

Here Comes the Wave

The first issue is the sheer number of dizzy patients coming our way. With extended life spans and the Boomer explosion, we need to be prepared to accurately and cost-effectively diagnose and treat patients complaining of dizziness and/or vertigo. If the numbers in the paragraph below, indicating a doubling every 15 or so years, predict the future, we have a long way to go and a short amount of time to do it.

“In their analysis of information from the Medical Expenditure Panel Survey and the National Hospital Ambulatory Medical Care Survey, Newman-Toker and his colleagues found that while the number of annual emergency room visits for all complaints nationally increased by 44 percent (from 70.7 million to 101.9 million) from 1995 to 2011, the annual number of visits for dizziness jumped even more, by 97 percent (from 2 million to 3.9 million) over the same period.”

Is Anybody Listening?
The second issue is an apparent failure to respond to the evidence. At the same time that numerous articles are coming out showing the inefficiency of ordering CT scans for dizziness, the percentage of patients undergoing CT scan has increased by about 200%.

“They also found that the proportion of dizziness visits that involved advanced imaging technology increased from 10 percent in 1995 to nearly 40 percent in 2011, while the use of imaging increased even more in patients without dizziness, whose scans increased from 3.4 percent to 19 percent over the study period.”

What Makes More Sense?
Does it makes sense to test for something unlikely to be the problem first, but not test for the most likely cause of the complaint? This is the case with dizzy patients. This study lists “otologic/vestibular” as the most common diagnostic category, yet almost 40% underwent neuroimaging (Mostly CT scan). Previous studies show that only about 10% of dizzy patients get any kind of vestibular screening in the Emergency Room.

“The proportion undergoing diagnostic imaging by computed tomography (CT), magnetic resonance imaging (MRI), or both in 2011 was estimated to be 39.9% (39.4% CT, 2.3% MRI). HCUP-CCS key diagnostic groups for those presenting with dizziness and vertigo included the following (fraction of dizziness visits, cost-per-ED-visit, attributable annual national costs): otologic/vestibular (25.7%; $768; $757 million), cardiovascular (16.5%, $1,489; $941 million), and cerebrovascular (3.1%; $1059; $127 million). Neuroimaging was estimated to account for about 12% of the total costs for dizziness visits in 2011 (CT scans $360 million, MRI scans $110 million.”

The Bottom Line?
The right hand needs to talk with the left hand. In my role as part of the group representing Audiology at the American Medical Association, I am responsible for staying on top of vestibular codes and trends. You would think that somewhere in this process, either at the AMA or CMS (Medicare), I would have the opportunity to present this information to policy makers. Surely, someone at a high level would be interested in saving $1 billion a year. Surely, they wouldn’t knowingly discourage vestibular screening by cutting the reimbursement in half. Surely, they would want to discourage the performance of a test (CT Scan) that is expensive, used frequently, potentially harmful, rarely needed and often inaccurate.


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