Family medicine residents remain unaware of hospital charges for diagnostic testing.

BACKGROUND AND OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) has mandated that resident training programs incorporate instruction on the economic reality of health care. Studies over the past 15 years have demonstrated that resident physicians, as well as physicians in practice, are unaware of the charges associated with commonly ordered diagnostic tests. The last study to document family medicine residents' knowledge of the hospital charges associated with diagnostic studies was published over 10 years ago. With increasing emphasis on cost containment in the past decade, we attempted to determine if any change over time had occurred in family medicine residents' knowledge of the charges associated with commonly ordered diagnostic studies. METHODS: Sixteen common laboratory and radiology tests were surveyed and distributed to 30 resident physicians at a community-based, family medicine residency program. Estimates within 25% of the actual charges were considered correct. These results were then compared to prior similar research. Correlation between years of completed training and percentage of correct estimates was also assessed. RESULTS: A total of 26 of 30 surveys (87%) were completed and compared to actual charges. Only 81 (19%) of 416 estimates were within 25% of actual charges. No improvement was noted with advanced years of training. Compared to previous work, this study does not show gains in cost awareness among family medicine residents. CONCLUSIONS: Family medicine residents remain largely unaware of the hospital charges associated with diagnostic studies despite increasing emphasis on cost containment. These results will hopefully expose the persistent lack of awareness of the costs associated with ordered radiology and laboratory studies.

Does early ED CT scanning of afebrile patients with first episodes of acute pancreatitis ever change management?

Rising utilization of computed tomography (CT) imaging early in the course of acute pancreatitis (AP) has been recently reported. However, radiographic demonstration of the degree of necrosis or the presence of complications is not fully apparent within the first days of an acute attack. The objective of this study was to examine if CT scanning early in the course of disease (<48 h of symptoms) in afebrile patients with an emergency department (ED) diagnosis of first episode of AP revealed any unanticipated pathology that altered clinical management. A retrospective chart review of all adult patients with a first episode of AP without fever admitted to the medical ward through the ED of our community hospital from January 1, 2011 to May 31, 2012 was performed. In cases in which CT scans were performed, the record was reviewed to determine if any unexpected findings were uncovered or if patient care was altered by the CT report. Two hundred forty-eight patients were admitted with an ED diagnosis of AP; 26.2 % (n = 65) met inclusion criteria; 70.8 % (n = 46) received a CT scan within 48 h of symptom onset. No patient that underwent CT scanning had an unexpected finding (95 % CI, 0.923-1.0). Our results demonstrate that afebrile patients with first episodes of AP do not benefit from early abdominal CT imaging. These results support the ACR Appropriateness Criteria recommendation that CT is not indicated in the first 48 h after symptom onset in unequivocal cases of AP.

The Pulmonary Embolism Rule-Out Criteria rule in a community hospital ED: a retrospective study of its potential utility.

BACKGROUND: The Pulmonary Embolism Rule-Out Criteria (PERC) rule identifies patients who can be safely discharged from the emergency department (ED) without undergoing laboratory or radiological investigation for possible pulmonary embolism (PE). It was shown to be 99% sensitive in a large validation series. Our objective was to assess the PERC rule's performance in a representative US community hospital. METHODS: A chart review of ED patients receiving computed tomographic scans (CTS) for possible PE during a 4-month study period was performed. The PERC rule was applied to this cohort, and its sensitivity and negative predictive value were determined. RESULTS: Two hundred thirteen patients underwent chest CTS to "rule out" PE. Forty-eight patients met PERC rule criteria, and all had negative CTS. Of the remaining 165 patients, 18 patients (11%) had scans positive for PE. The overall prevalence of PE was 8.45% (95% CI, 5.22-13.24%). The PERC rule's sensitivity was 100% (95% CI, 78.12-100%), with a negative predictive value of 100% (95% CI, 90.80-100%). Application of the PERC rule at the point-of-care would have reduced CTS by 23%. CONCLUSIONS: In our community hospital, the PERC rule successfully identified ED patients who did not require CTS evaluation for PE. Had the PERC rule been applied, nearly one-quarter of all CTS performed to "rule out PE" could have been avoided.