Practical Analytic Approaches to Healthcare Challenges
Dizziness accounts for 3.3% of all Emergency Department (ED) visits annually. This corresponds to about 2.6 million ED visits per year in the United States.¹ A Computed Tomography (CT) scan of the head is one of the most frequently used diagnostic procedures for evaluation of dizziness in the ED, despite various studies reporting its low sensitivity, low predictive value, and low diagnostic yield for evaluation of dizziness.²
The American College of Emergency Physicians (ACEP) recommends against the use of CT scans of the head in the ED for asymptomatic adult patients with a normal neurological evaluation, and without significant trauma.³ The ACEP considers use of CT scans of the head for dizziness as inappropriate and wasteful, as it is not conclusive. The test is also expensive and potentially hazardous due to unnecessary exposure to radiation.
To identify the prevalence of CT scans of the head in the ED for patients reporting dizziness, we conducted an analysis on a large commercial dataset with claims from major health plans (approx. 13 million members). We used MedInsight’s Health Waste Calculator (HWC) application to identify service count, waste index (percentage of services measured that were wasteful), and associated costs of CT scans of the head for dizziness in ED. The HWC identifies CT scans of the head as not wasteful for members with associated head injury, benign or malignant tumors of head and neck or neurological deficit. Table 1 summarizes the utilization of CT scans of the head for dizziness in ED for a commercial population in the above dataset for 2017. There were 6,794 CT scans of the head for dizziness in 2017, out of which 4,066 (60%) services were wasteful. This was almost 0.2% of all the wasteful services for 2017, and contributed to 0.8% of all the wasteful health expenditure for 2017.
Table 1: Utilization of CT Scans of the Head for Dizziness in ED – 2017
Analysis of Utilization services by age showed higher utilization of CT scans of the head in members with advancing age. Figure 1 shows the distribution of population and services of CT scans of the head for dizziness in ED by age. The proportion of services was higher in members above the age of 50. This was in contrast to the pattern seen in members less than 50 years old.
Figure 1: Distribution of Population & Services of CT Scans of the Head for Dizziness in ED by Age – 2017
Further Analysis of utilization of CT scans of the head services by gender (summarized in Table 2) showed higher utilization, as well as higher waste index in females, as compared to males. A total of 3,377 CT scans of the head were performed in females, as compared to 3,017 in men. The waste index in females was 62%, as compared to 57% in males. The prevalence of dizziness was also seen to be higher in females as compared to males. This was in line with reports of dizziness in females in various publications.⁴
Table 2: Services of CT Scans of the Head for Dizziness in ED by Gender – 2017
Interestingly, although there was high utilization of services in adults above the age of 50, the prevalence of wasteful services was found to be slightly lower in this age group for both genders. Figure 2 shows the waste index by age bands for both genders. The waste index (WI) in young adults (less than 50 years old) was above 60% and decreased gradually to around 50% for members older than 70 for both genders.
Figure 2: Waste Index of Head CT Scans for Dizziness in the Emergency Department by Age Band – 2017
To review the year over year trend of services and cost associated with these services, we analyzed head CT scans for dizziness in the ED from two years prior for the same population. Table 3 displays the utilization and cost analysis for this service.
Table 3: Trend in Utilization and Cost of Head CT Scans for Dizziness in the Emergency Department: 2015-2017
Despite the recommendations against its usage from various medical societies, such as American Society of Emergency Physicians and associations such as Choosing Wisely, the waste index was consistently above 50% for all three years. Figure 3 summarizes the trend of utilization of CT scans of the head in the ED for dizziness for 2015-2017. An overall increase in the cost of these services was noticed, although there was a slight decrease in provision of the services over the years. Further, the contribution of this series to the overall waste increased year over year, both in terms of wasteful services and wasteful dollars.
Figure 3: Service Count and Cost Trend for Head CT Scans for Dizziness in the Emergency Department: 2015-2017
It is important to note that claims data alone allows only an approximate identification of wasteful CT scans of the head in the ED for dizziness. The HWC application identifies wasteful services, which can help identify opportunities to address avoidable costs and achieve appropriate clinical care. This analysis confirmed the high prevalence of wasteful CT scans of the head for a commonly reported problem in the ED in line with various publications. Studies recommend that dizziness requiring only symptomatic management should be carefully differentiated from cases requiring further diagnostic work-up.⁵
- Mitsunaga M, Yoon H. Head CT Scans in the Emergency Department for Syncope and Dizziness. American Journal of Roentgenology. 2015;204(1):24-28.
- Lawhn-Heath C, Buckle C, Christoforidis G, Straus C. Utility of head CT in the evaluation of vertigo/dizziness in the emergency department. Emergency Radiology. 2012;20(1):45-49.
- ACEP – Avoid head CT for asymptomatic adults with syncope | Choosing Wisely [Internet]. Choosingwisely.org. 2019 [cited 8 January2019]. Available from: https://www.choosingwisely.org/clinician-lists/acep-avoid-head-ct-for-asymptomatic-adults-with-syncope/ (https://www.choosingwisely.org/clinician-lists/acep-avoid-head-ct-for-asymptomatic-adults-with-syncope/)
- Kerber K, Callaghan B, Telian S, Meurer W, Skolarus L, Carender W et al. Dizziness Symptom Type Prevalence and Overlap: A US Nationally Representative Survey. The American Journal of Medicine. 2017;130(12):1465.e1-1465.e9.
- Ahsan S, Syamal M, Yaremchuk K, Peterson E, Seidman M. The costs and utility of imaging in evaluating dizzy patients in the emergency room. The Laryngoscope. 2013;123(9):2250-2253.