Five Ways to Reduce Emergency Care Costs

Summary and Comment |
February 17, 2014

Five Ways to Reduce Emergency Care Costs

  1. Cheryl Lynn Horton, MD

Experts derived a top-five list of frequently ordered, expensive clinical actions that have little or no benefit and should be avoided.

  1. Cheryl Lynn Horton, MD

An expert panel of emergency physicians from a healthcare system in Massachusetts identified 17 tests, treatments, and disposition decisions that are expensive, frequent, and of little or no benefit to most patients. These items were included in a survey of 283 emergency medicine clinicians from the same system. Based on the responses, the panel created a top-five list of actions to reduce the cost of emergency care:

1. Do not order computed tomography (CT) imaging of the cervical spine for patients who do not meet the National Emergency X-Radiography Utilization Study (NEXUS) criteria or the Canadian C-Spine Rule.

2. Do not order CT imaging to diagnose pulmonary embolism without first risk stratifying by determining pretest probability and measuring d-dimer in low-risk patients.

3. Do not order magnetic resonance imaging of the lumbar spine for patients with low back pain without high-risk features.

4. Do not order CT imaging of the head for patients with mild traumatic head injury who do not meet the New Orleans Criteria or the Canadian CT Head Rule.

5. Do not order coagulation studies for patients without hemorrhage or suspected coagulopathy.


This list identifies clinical actions that have little value and contribute to rising healthcare costs. Imaging is the second most expensive decision emergency providers make (hospital admission is the first), and not surprisingly, four of the five items on the list pertain to imaging without clinical indication. It is important that emergency medicine specialists take the lead in defining overuse in emergency care, lest regulators or insurers, with less insight into the practice of emergency medicine, do it for them.

Dr. Horton practices in the same system as the study authors but was not involved in the study. One of the authors, Dr. Raja, is an NEJM Journal Watch Emergency Medicine editor. He was not involved in writing or reviewing this summary.

Editor Disclosures at Time of Publication

  • Disclosures for Cheryl Lynn Horton, MD at time of publication Nothing to disclose


Reader Comments (6)

Terril Shorb, Ph.D. Other, Other, Prescott College Community Development program

From a patient (or patient’s family) perspective, the very reason for the ER visit often is that no or few other options are available. Here in rural, central Arizona, for example, non-ER urgent care is sketchy and often not available on Sundays. Do stats show a correlation between people’s 24/7 access to walk-in urgent clinic care and reduced incidence of ER visits?

Samuel Leonard, BS, MS, MD, MBA Physician, Family Medicine/General Practice

A very useful service

Behzad Pavri, MD Physician, Cardiology, Philadelphia

Another addition to this list would be unnecessary testing for low-risk patients who present with what is CLEARLY vasovagal syncope. We often see admission for observation, carotid Doppler, head CT, echocardiography, and referral to neurology for patients who ought to have only reassurance, advise about fluids/salt/recumbency, and be sent home.

Maurice C. Carter, M.D. Physician, Orthopedics, New York

It is my experience that imagings of musculoskeletal conditions are used far too often and particularly egregious uses occur when physicians working for plaintiff''s attorneys are involved. New York worker's compensation rules have tried to limit this, but abuse continues.

F X WORTHINGTON Physician, Cardiology

These realistic cautions will have no effect on clinical practice until
strong pressure can be brought upon the legal system.
Good Luck.

JOHN PEFFER Physician, Family Medicine/General Practice, Military

For the life of me, I don't understand the recommendation from ACEP or the ACP about D-dimer in low probability cases.

I use D-dimer to help me discriminate Intermediate pre-test probability. If they're high pre-test, I don't get it because I'm already suspicious for a PE and if they're low pre-test probability by a clinicial deciison rule or my own judgement, I don't get the D-dimer either.

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