Tuesday, March 15, 2011

No MRI in the Emergency Department

At a major hospital in Israel, one with a very extensive emergency department, they do not have an MRI for the ED. Why? The payment for an emergency room visit is a flat rate, and a low one at that, regardless of diagnosis. While they have X-Rays and CT scanners, they cannot justify the cost of an MRI. Besides, noted my host, "How often do you really need an MRI for an emergency room visit?"

What a contrast with the US, where an MRI in each hospital's ED is de rigueur. But the same question could be asked, "How often do you really need an MRI for an emergency room visit?" Not, how often is one used? This article, for example, shows a tripling of MRI and CT usage in the ten years after 1998. The JAMA abstract is here. (It doesn't separate the two modalities.) During this same time period, there was a small increase in the prevalence of life-threatening conditions; but there was no change in prevalence of visits during which patients were either admitted to the hospital or to an intensive care unit. Visits during which CT or MRI was obtained lasted 126 minutes longer than those for which CT or MRI was not obtained.

So, how often is an MRI really needed? At what cost to society?

23 comments:

Barry Carol said...

I think widespread MRI use in U.S. ED’s is classic defensive medicine, though it also helps to drive revenue and some patients may be disappointed if they don’t get it. We need to take medical dispute resolution out of the hands of juries in favor of health courts or expert panels and give doctors robust safe harbor protection from lawsuits when they follow evidence based guidelines where they exist. After we enact tort reform along these lines, we can change the ED payment model to a relatively low flat fee regardless of the diagnosis.

Paul Levy said...

From Facebook:

Beverly: That factoid really tells us something about the U.S. system, doesn't it. Amazing.

Jonathan: Actually, most of the EDs I have worked in here in the US don't have access to emergent MRI. When I was a resident at BIDMC we frequently got transfers from outlying EDs only due to the need for emergent MRI.

I can count the MRIs I have ordered from the ED in the past 4 years on my my fingers and toes... the circumstances that trigger a true need for emergent MRI are rather limited. However, a few of these 20-ish MRIs led to very important life-threatening diagnoses which could not be made in other ways (a couple of epidural abscesses come to mind).

In my opinion, access to MRI is an important diagnostic tool which I infrequently need, but when I need it... I really need it. Perhaps the key is to ensure MRI from the ED is only used when it is truly indicated.

Anonymous said...

I am wondering if Israel and other countries with gov't run health care also have private foundations and fun raisers to raise additional money and purchase equipment and services.

Paul Levy said...

Yes, they certainly do in Israel, both the private hospitals and the government owned hospitals.

Nurse K said...

There are plenty of dumb MRIs ordered (eg. knee, back for chronic pain, chronic headaches, etc.), but I think they really do help if you (or the neurologist who is covering for strokes/tpa/cath for intra-arterial tpa) are not sure if a patient is having a stroke or not.

Paul Levy said...

I would be interested in hearing from neurologists, as I understood that a CT scan could give them what they need on that front.

That being said, not all EDs are at stroke centers, where that kind of diagnosis is made in any event.

@Scanman said...

From Twitter:

I agree. MRI is not an emergency diagnostic modality.

EMS Man said...

While I agree that the MRI is an abused diagnostic resource, the financial penalty of not having the MRI onsite typically falls on the hospital. CMS has set the DRG's in such a way that having a MRI allows for significant gain by a facility to have an MRI onsite. The facility that has the MRI would be able to include that into the facilities coffers without the added expense of transportation to the MRI. If an emergency room in the Metro-Boston area needed to send a patient out for an MRI that is 5 miles away, the DRG charges the ER would have to pay would be over $285 each way ( Based on 2010 CMS Massachusetts Rate Schedule, Locality 1, BLS Non-Emergent). Include the large number of MRI's that every ER orders every year, I ask where is the incentive for a facility to NOT have an MRI onsite?

As was mentioned earlier, most facilities have fundraisers and donations to subsides a significant portion or all of the capitol needed to install an MRI (typically the largest expense). I am confident the MRI is a self sustaining entity of any facility, as we see stand alone MRI's across the state. If, once the MRI is in place, it can make money, why wouldn't an ER have one? As is typical in our current health care payer system, excess is rewarded. The dollar drives the "need" for MRI's in ER's

76 Degrees in San Diego said...

My 89 y.o. patient, whom I admitted two days ago for some slightly semi-slurred speech, had a "normal for age CT" but two fresh thombotic infarcts on MRI. And I was thinking it was just her mild dementia...

Paul Levy said...

Admitted, as in in-patient, or sent to ED?

76 Degrees in San Diego said...

"Admitted" from the E.D. under outpatient observation status with neuro monitoring....now changed to "admitted inpatient"

Anonymous said...

So how did the emergent MRI change your management?

76 Degrees in San Diego said...

It led to the discovery of a high grade carotid stenosis on the contralateral side and is enabling a full family discussion about hospice vs. future carotid intervention...The risk of a future stroke with possible future inability to be cared for by her/his family in a home environment is being weighed...

MedStudent in Israel said...

I don't see that spending thousands of dollars on an MRI in order to enable a family discussion is money well spent - especially since the CT scan which would have been redone in a couple of days (due to symptoms not resolving) would probably have picked up the stroke.

This is what is driving the waste of the US medical system - spending such huge sums for such a little gain (not that it is totally worthless, but not worth the cost of an MRI)

76 Degrees in San Diego said...

Good question. But the answer requires knowledge of true costs(not charges):
1. what is the cost of an extra day in the hospital
2. what is the difference in cost between an MRI and at CT(which still might not have shown the stroke)
3. Is the patient on a full risk hospital contract where the hospital bears the cost...and the cost of not being able to admit another patient who is waiting in the ER for a open bed for another day.
4. What is the cost to the hospital if it has to go on ER bypass because of an unavailable bed.
5. Solving for the above probably requires multivariable calculus(I only went to medical school).

msshamma said...

I have been working night shift for the last 16 years. I do not have MRI available at night, and I have never ordered one. I have never encountered a problem due to the lack of MRI. When patients or their companions ask, I simply answer that we do not have MRI available, period.

Anonymous said...

I work in a 32k/yr semi-rural ED. We are not allowed to order MRI from ED, rules from hospital admin. I have worked in ED's 24 years and have ordered fewer than 10 MRI's in that time. MRI is not needed for ED's.

Anonymous said...

This is simple. In the U.S. you cannot keep TPA out of your drug formulary then use "failure to stock TPA" as a defense in a medical malpractice lawsuit. "Failure to perform an MRI" is one of the current ploys used by the legal community to sue their prey. As long as this is a risk, you cannot withhold the MRI machine as a defense tool for the Emergency Physician.

76 Degrees in San Diego said...

Understood. However, a normal MRI in the case presented would have allowed home discharge from the ER rather than a night in the "expensive hotel".

James said...

What data do we have comparing outcomes with the two approaches?

Anonymous said...

The only time an emergent MRI is indicated is to rule out cauda equina and possibly epidural abscess. My hospital does not have evening/overnight MRI, so if someone presents with a clinical suspicion for cauda, I transfer them to a hospital that has MRI availability.

susan256 said...

These are excellent points and areas we, as patients, need to seriously consider. What's the cost to society as a whole if we just head nod when our doctor says we need this? Maybe we don't. We should ask more questions: This video gives some ideas: http://whatstherealcost.org/video.php?post=five-questions

76 Degrees in San Diego said...

My point was that the cost of not doing the MRI was that of missing a thrombotic stroke. Ordering the MRI meant an overnight admission to the hospital. I didn't have a problem with that.