Where Are the Greatest Risks for Choosing Unwisely? A Survey of Emergency Department Clinicians

Quality improvement activities targeting low-value care are important to ensure that scarce healthcare resources are used responsibly. However, there has been little systematic research into what diagnostic testing is considered by emergency department (ED) clinicians to be at risk of unwarranted variation or potentially low value.

This study aimed to determine the views of ED clinicians on which diagnostic tests are highest risk for variation and/or low-value care.

A voluntary electronic survey was distributed to emergency clinicians across Australia and Aotearoa New Zealand. Respondents were asked to identify which investigations were high risk for unwarranted variation and/or low value.

There were 184 responses (75 doctors, 82 nurses, and 27 other) analysed. Investigations identified included D-dimer (42%), venous blood gas (VBG) (39%), C-reactive protein (CRP) (35%), and plain x-rays of the abdomen (35%). Compared to nursing staff, medical staff perceived CRP (51% vs. 24%), urine drug screening (55% vs. 21%), clotting profile (48% vs. 24%), salicylate level (29% vs. 7%), erythrocyte sedimentation rate (41% vs. 10%), and abdominal x-ray (67% vs. 16%) at higher risk. D-dimer and VBG were seen to be high risk by both groups. Routinely ordered tests (e.g., full blood examination) were considered relatively low risk.

Several commonly used investigations are perceived to be at high risk of unwarranted variation or low-value care. These risks are perceived differently by different groups of emergency clinicians. Potential future directions include understanding the reasons for variation and efforts to reduce variation, including audit and feedback.