Choosing wisely in emergency medicine: Early results and insights from the ACEP emergency quality network (E-QUAL)

Published:January 17, 2020DOI:


      • Survey data from a large national sample of volunteer hospital-based EDs shows wide variation in imaging utilization
      • ED sites with sustained participation in a national QI initiative showed significant reductions in imaging utilization
      • Imaging utilization rates from top-performing ED sites can serve as performance improvement targets for future QI efforts
      • Efforts to translate the Choosing Wisely campaign into practice should utilize benchmarking to sustain practice improvements



      To characterize performance among ED sites participating in the Emergency Quality Network (E-QUAL) Avoidable Imaging Initiative for clinical targets on the American College of Emergency Physicians Choosing Wisely list.


      This was an observational study of quality improvement (QI) data collected from hospital-based ED sites in 2017–2018. Participating EDs reported imaging utilization rates (UR) and common QI practices for three Choosing Wisely targets: Atraumatic Low Back Pain, Syncope, or Minor Head Injury.


      305 ED sites participated in the initiative. Among all ED sites, the mean imaging UR for Atraumatic Low Back Pain was 34.7% (IQR 26.3%–42.6%) for XR, 19.1% (IQR 11.4%–24.9%) for CT, and 0.09% (IQR 0%–0.9%) for MRI. The mean CT UR for Syncope was 50.0% (IQR 38.0%–61.4%). The mean CT UR for Minor Head Injury was 72.6% (IQR 65.6%–81.7%). ED sites with sustained participation showed significant decreases in CT UR in 2017 compared to 2018 for Syncope (56.4% vs 48.0%; 95% CI: −12.7%, −4.1%) and Minor Head Injury (76.3% vs 72.1%; 95% CI: −7.3%, −1.1%). There was no significant change in imaging UR for Atraumatic Back Pain for XR (36.0% vs 33.3%; 95% CI: −5.9%, −0;5%), CT (20.1% vs 17.7%; 95% CI: −5.1%, −0.4%) or MRI (0.8% vs 0.7%, 95% CI: −0.4%, −0.3%).


      Early data from the E-QUAL Avoidable Imaging Initiative suggests QI interventions could potentially improve imaging stewardship and reduce low-value care. Further efforts to translate the Choosing Wisely recommendations into practice should promote data-driven benchmarking and learning collaboratives to achieve sustained practice improvement.


      E-QUAL (The Emergency Quality Network), QI (Quality Improvement)


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