PROCEEDINGS—EXECUTIVE SUMMARY

Developing a Research Agenda to Optimize Diagnostic Imaging in the Emergency Department: An Executive Summary of the 2015 Academic Emergency Medicine Consensus Conference Jennifer R. Marin, MD, MSc, and Angela M. Mills, MD

Abstract The 2015 Academic Emergency Medicine (AEM) consensus conference, “Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization,” was held on May 12, 2015, with the goal of developing a high-priority research agenda on which to base future research. The specific aims of the conference were to: 1) understand the current state of evidence regarding emergency department (ED) diagnostic imaging utilization and identify key opportunities, limitations, and gaps in knowledge; 2) develop a consensus-driven research agenda emphasizing priorities and opportunities for research in ED diagnostic imaging; and 3) explore specific funding mechanisms available to facilitate research in ED diagnostic imaging. Over a 2-year period, the executive committee and other experts in the field convened regularly to identify specific areas in need of future research. Six content areas within emergency diagnostic imaging were identified prior to the conference and served as the breakout groups on which consensus was achieved: clinical decision rules; use of administrative data; patient-centered outcomes research; training, education, and competency; knowledge translation and barriers to imaging optimization; and comparative effectiveness research in alternatives to traditional computed tomography use. The executive committee invited key stakeholders to assist with planning and to participate in the consensus conference to generate a multidisciplinary agenda. There were 164 individuals involved in the conference spanning various specialties, including emergency medicine (EM), radiology, surgery, medical physics, and the decision sciences. This issue of AEM is dedicated to the proceedings of the 16th annual AEM consensus conference as well as original research related to emergency diagnostic imaging. ACADEMIC EMERGENCY MEDICINE 2015;22:1363–1371 © 2015 by the Society for Academic Emergency Medicine

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t’s a busy evening in the emergency department (ED), and a 35-year-old female presents with abdominal pain and vomiting. You suspect food poi-

soning based on further history, but decide to obtain a computed tomography (CT) scan to confirm that there is nothing more significant. There are several other

From the Departments of Pediatrics and Emergency Medicine, University of Pittsburgh School of Medicine (JRM), Pittsburgh, PA; and the Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania (AMM), Philadelphia, PA. Received July 2, 2015; accepted July 5, 2015. Dr. Marin was supported by the Agency for Healthcare Research and Quality (R13HS023498-01); receives support as teaching faculty for 3rd Rock Ultrasound, LLC; and has served as a consultant for Venaxis, Inc. Dr. Mills is a consultant for LifeWatch Services and Venaxis, Inc. The conference was supported in part by the Agency for Healthcare Research and Quality (1R13HS023498-01) and the National Institute of Biomedical Imaging and Bioengineering (1R13EB019813-01). Additional funding was provided by the American College of Radiology, the Radiological Society of North America, the American Association of Physicists in Medicine, the American College of Emergency Physicians, the Council of Emergency Medicine Residency Directors, the American Society of Emergency Radiology, the Emergency Medicine Residents’ Association, Children’s Hospital of Pittsburgh, Division of Pediatric Emergency Medicine, the Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, and the American Academy of Emergency Medicine. Supervising Editor: Christopher R. Carpenter, MD, MSc. Address for correspondence and reprints: Jennifer R. Marin, MD, MSc; e-mail: [email protected].

© 2015 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12818

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patients awaiting a CT, and it takes a while to obtain the imaging. Shortly after returning from the CT scanner, she develops an urticarial skin reaction that is treated with diphenhydramine. Several hours into her stay the CT is read as negative. After receiving intravenous fluids and ondansetron she feels better and is discharged. Later, a 40-year-old male presents with right flank pain and microscopic hematuria. You have a high suspicion for nephrolithiasis and treat him with fluids and pain medication. He inquires about a CT to confirm the diagnosis and you explain that an ultrasound would be the optimal test in this scenario and explain your rationale. You then begin to worry about the possibility of him returning to the ED and you getting “dinged” for the unscheduled return. If he does not come back to the ED, and follows up with his primary care provider, you believe that they will probably order a CT anyway. In the end, you order a CT to confirm the diagnosis and reassure him. The CT demonstrates a 2-mm stone in the left distal ureter and, additionally, an adrenal adenoma. When you discuss the results with the patient, he is distressed and confused by the diagnosis of the adrenal adenoma and worries that he has cancer (Data Supplement S1, available as supporting information in the online version of this paper). These are just a few of the scenarios that served as the foundation for the 2015 Academic Emergency Medicine (AEM) consensus conference, “Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization.” The purpose of this consensus conference was to develop a high-priority research agenda on which to base future research regarding ED diagnostic imaging. CURRENT STATE OF DIAGNOSTIC IMAGING For decades, medical imaging has dramatically changed the way we care for patients in the ED. Several modalities, specifically plain radiography and CT imaging, and in some centers even magnetic resonance imaging (MRI), are available to us directly within the ED. In addition to accessibility, the speed with which many of today’s imaging studies are performed often makes ordering and obtaining these tests seamless. Since its introduction into medicine in 1972, CT specifically has been able to provide lifesaving diagnoses as well as alternative diagnoses that may not have initially been at the top of the differential diagnosis. In some cases, by making a definitive diagnosis, these tests allow patients to be discharged home, thereby avoiding the cost of hospital admission. Over time, use of imaging has increased in the ED.1–4 In fact, by 2010, nearly half of all ED visits included at least one imaging test.1 Between 2001 and 2010, the proportion of ED visits with CT or MRI ordered nearly tripled, from 6% in 2001 to 17% in 2010, and ultrasound use doubled to 4%.1 There are data to suggest that in recent years a plateau or even decline in ED imaging testing may be evident.5–8 Nonetheless, the media, policymakers, patients, and health care providers have called our current level of utilization into question.9–16 In addition, many studies have suggested that outcomes are not necessarily improved with more imaging.17–22 In

fact, current practices may be detrimental to our patients. In a 2013 editorial in JAMA Pediatrics, Schroeder and Redberg23 discuss the inappropriate use of imaging in children. They cite specific examples of common complaints for which there are alternatives to imaging altogether or, in cases where imaging is necessary, alternatives to radiating modalities that should be considered. These recommendations are also translatable to adult ED patients.24,25 Recently, Gwande26 published an article in the New Yorker entitled, “Overkill,” in which he highlights the concept of “low-value” (or what he refers to specifically as “no-value”) care, as a result of the unnecessary testing Americans receive. In the article he references a study in which at least one-quarter and up to 42% of Medicare patients receive at least one unnecessary test or treatment. As with all testing or interventions performed, there are risks to unnecessary imaging tests. Some have suggested that imaging increases ED length of stay rather than provide more expedited, efficient care.20,27 There are risks of false-positive findings when the interpreting physician, who can be the radiologist or the ED physician, misreads an imaging test.28 Incidental findings are particularly concerning, given the downstream testing that may be unnecessary and can occur as a result.29–32 Intravenous contrast carries a risk of acute kidney injury and of allergic reactions.33,34 Although some imaging modalities are present in the ED, patients must still be transported from their rooms to the imaging suite, and for critically ill patients in particular, this presents safety as well as logistic challenges. For pediatric patients, even as rapid as CT imaging has become, many, depending on the child and the examination (e.g., CT neck with contrast), may require sedation to obtain an adequate study, which carries with it its own risks. As health care providers, it would be ideal to not have to be concerned with the costs of the care we provide; however, this is the reality of our system. Private insurance companies and the Centers for Medicare and Medicaid Services may not reimburse what are considered to be inappropriate imaging studies.35 Finally, there is the risk associated with the radiation exposure of some ED imaging modalities. Over time, the U.S. population has been exposed to higher amounts of ionizing radiation. As of 2006, medical imaging was responsible for almost half of all radiation exposures, with CT responsible for nearly half of those exposures.36 The National Council on Radiation Protection and Measurements estimated radiation exposures of over 6 mSv per year per individual in 2006, which is 1.7 times what the radiation exposure was in the 1980s.36 Recent epidemiologic studies suggest a measurable risk of cancer from childhood exposures to CT.37,38 There remains more to learn regarding these risks. Nonetheless, radiation exposure from medical imaging is an issue that has received significant media attention over the past several years9,39–41 and our patients are asking questions regarding the risks and necessity of some of our tests. Several national campaigns were launched in the past decade in an effort to educate health care practitioners and the public on appropriate imaging use and risks. Choosing Wisely is an initiative from the American

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Board of Internal Medicine, and many professional societies have published their Choosing Wisely lists of relevant scenarios where testing, including imaging, should be optimized.42 The American College of Emergency Physicians (ACEP) released its initial list in 2013,43 which includes “avoiding head CT scans in patients with minor head injury who are at low risk based on validated decision rules.”43 In 2014, ACEP released additional imaging-related recommendations as part of the Choosing Wisely initiative. The list includes avoiding imaging in adults with syncope and unremarkable neurologic examinations, patients with low pretest probability of pulmonary embolism, patients with uncomplicated nontraumatic back pain, and young healthy patients with known kidney stones and symptoms of uncomplicated renal colic. Image Gently was started by the Alliance for Radiation Safety in Pediatric Imaging in an effort to educate and promote pediatricspecific protocols and the safe imaging of children.44,45 Similarly, Image Wisely was subsequently developed through the joint efforts of the American College of Radiology, Radiological Society of North America, American Association of Physicists in Medicine, and American Society of Radiologic Technologists, to promote the safe and responsible imaging of adult patients.46,47 “Appropriate use of medical imaging shouldn’t always mean less imaging” was the title of a recent article by Bibb Allen, Jr., chair of the American College of Radiology Board of Chancellors.48 Although the article was written in the context of CT colonography for colon cancer screening, the concepts discussed are certainly

relevant to our use of ED imaging. Although there is a significant need for further research on how to best improve diagnostic imaging in the ED setting, there had not been a coordinated effort to advance the scientific knowledge of this topic.24 The goal of this consensus conference was not to discourage the use of diagnostic imaging. Rather, the overarching message was to optimize utilization—determine if imaging is truly needed and what the best test is for that patient at that time.24,25 CONFERENCE PLANNING Since 2000, AEM has held an annual research consensus conference. The purpose of the conference is to define a high-priority research agenda for a timely, important, clinically relevant emergency medicine topic. Through a competitive review process, the AEM editorial board selects a proposal 2 years in advance of the conference to allow for adequate planning. In May 2013, the proposal “Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization” was selected for the 2015 AEM consensus conference. The first year of planning was focused on fund-raising, grant writing, and marketing of the conference, while the second year was dedicated to breakout group meetings and development of draft content for eventual presentation and discussion on the conference day. The executive committee (Table 1) planned the conference via regular correspondence and in-person

Table 1 2015 AEM Consensus Conference Organizers Name

Institution

Specialty Pediatric EM EM Pediatric radiology Radiology

Co-Chair Co-Chair Executive committee member Executive committee member

EM EM Pediatric EM

Executive committee member Executive committee member Executive committee member

EM EM EM

Executive committee member Executive committee member Executive committee member

Donald M. Yealy, MD David C. Cone, MD

University of Pittsburgh University of Pennsylvania Emory University Massachusetts General Hospital Thomas Jefferson University Indiana University University of California at Davis University of Colorado George Washington University Massachusetts General Hospital University of Pittsburgh Yale University

EM EM

Christopher R. Carpenter, MD, MSc

Washington University

EM

Timothy B. Jang, MD Sandra K. Arjona Kathleen G. Seal

Harbor-UCLA Medical Center Academic Emergency Medicine Academic Emergency Medicine

EM

Melissa McMillian, CNP

Society for Academic Emergency Medicine Society for Academic Emergency Medicine Society for Academic Emergency Medicine Society for Academic Emergency Medicine

Executive committee member Editor-in-chief, Academic Emergency Medicine Guest editor, consensus conference proceedings Guest editor, original contributions Journal manager Technical editor and peer-review coordinator Grants and foundation manager

Jennifer R. Marin, MD, MSc Angela M. Mills, MD Kimberly E. Applegate, MD, MS James A. Brink, MD Brendan G. Carr, MD, MA, MS Jeffrey A. Kline, MD Nathan Kuppermann, MD, MPH Resa E. Lewiss, MD Jesse M. Pines, MD, MBA, MSCE Ali S. Raja, MD, MBA, MPH

LaTanya Morris Maryanne Greketis, CMP Holly Byrd-Duncan, MBA

Role

Education manager Meeting planner Marketing and membership

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meetings and identified six core areas that warranted further research in the area of ED diagnostic imaging: 1) clinical decision rules; 2) administrative data; 3) patient-centered outcomes research; 4) training, education, and competency; 5) knowledge translation and barriers to image optimization; and 6) comparative effectiveness research using alternatives to traditional CT use. The committee invited national experts to lead each of the breakout groups devoted to these areas (Table 2). Additionally, the committee and breakout groups leaders invited interested parties from various disciplines, including emergency medicine, radiology, pediatrics, surgery, decision sciences, and medical physics, as well as patients and representatives of stakeholder agencies, to participate in preconference planning. Specifically, each group was tasked with drafting a research agenda specific to that breakout group topic using the available literature as a foundation. Prioritized research agenda drafts were available to conference participants for review 2 weeks prior to the consensus conference day. In addition to the breakout group discussions that would take place on the day of the conference and serve as the crux of the conference, the Executive Committee planned for keynote addresses and panel discussions from notable experts with unique and varying perspectives. Role of Trainees In an effort to promote future research by promising young leaders in the field of EM, the executive committee encouraged resident and fellow attendance at the conference. We sent targeted e-mails to EM program chairs, the Council of Emergency Medicine Residency Directors, and the Emergency Medicine Residents’ Association, advertising the consensus conference and encouraging attendance by trainees. In addition, the executive committee held a travel award competition to cover the costs of travel for trainees with interest in emergency imaging research. After careful review of the 66 applications, we selected 15 trainees (11 residents, three fellows, and one medical student). Awar-

dees were assigned to their choice of breakout groups and were integral to conference planning for the year prior to the conference, as well as to activities on the day of the conference, including taking notes during the breakout groups, advertising and chronicling on social media, and coordinating voting within breakout groups. Trainees also had an opportunity to participate as coauthors on the manuscript products. Conference Aims The conference was a multidisciplinary collaborative effort and the specific aims were to: 1) understand the current state of evidence regarding ED diagnostic imaging utilization and identify key opportunities, limitations, and gaps in knowledge; 2) develop a consensus-driven research agenda emphasizing priorities and opportunities for research in ED diagnostic imaging; and 3) explore specific funding mechanisms available to facilitate research in ED diagnostic imaging. The purpose of the conference was not to make recommendations on imaging use, promote or disparage any particular imaging modality, or present a review of the literature. While the primary goal of the conference was to develop a prioritized research agenda, an additional goal was to promote an arena for multidisciplinary collaboration across several specialties and disciplines. At the conclusion of the conference, a networking reception was held to facilitate collaboration and allow conference participants to interact with other attendees as well as presenters, funders, and policymakers. Conference Agenda (Figure 1) The conference took place on May 12, 2015, just prior to the annual meeting of the Society for Academic Emergency Medicine. To start, Dr. David Cone, editorin-chief of AEM, delivered a welcome address, describing the history of the AEM consensus conference and discussing the goals of the conference. The conference co-chairs, Drs. Jennifer Marin and Angela Mills, provided a summary of the salient existing literature on ED diagnostic imaging, an introduction to those involved in

Table 2 Breakout Groups Group Number

Group Title

1

Clinical decision rules for emergency diagnostic imaging

2 3

Using administrative data for emergency imaging research Patient-centered outcomes research

4

Training, education, and competency

5

Knowledge translation and barriers to imaging optimization

6

Comparative effectiveness research: alternatives to traditional CT use

Group Leaders

Group Leaders’ Institution

Nathan Kuppermann, MD, MPH James Holmes, MD, MPH Jeffrey Kline, MD Keith Kocher, MD, MPH Jay Schuur, MD, MHS Erik Hess, MD, MSc Corita Grudzen, MD, MSHS Kimberly Applegate, MD, MS Resa Lewiss, MD Esther Chen, MD

University of California at Davis University of California at Davis Indiana University University of Michigan Brigham and Women’s Hospital Mayo Clinic New York University Emory University University of Colorado University of California at San Francisco University of Calgary Massachusetts General Hospital Columbia University Yale University Duke University Brigham and Women’s Hospital

Eddy Lang, MD Ali Raja, MD, MBA, MPH Peter Dayan, MD, MSc Christopher Moore, MD Joshua Broder, MD Aaron Sodickson, MD, PhD

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Figure 1. Conference day agenda.

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conference planning, and a summary of the day’s events. Nate Kuppermann, MD, MPH, chair of the Department of Emergency Medicine and professor of pediatrics at UC Davis, gave the first keynote address. A well-known epidemiologist and pediatric emergency physician, with expertise in emergency care research, Dr. Kuppermann provided his perspective on diagnostic imaging via his extensive research experience surrounding clinical decision rules, clinical decision support, and shared decision-making.49 Helen Burstin, MD, MPH, Chief Scientific Officer of the National Quality Forum, delivered the second keynote address, which focused on imaging quality measures.50 Craig Blackmore, MD, MPH, director of the Center for Healthcare Improvement Science and a radiologist at Virginia Mason Medical Center, delivered the final keynote.51 Dr. Blackmore provided his expertise both as a health services researcher with a focus on imaging quality and efficiency and as an emergency radiologist. Two panel

discussions served to provide stimulating discussion surrounding topics of interest to practicing physicians as researchers. The first lunchtime panel was dedicated to policy measures and reimbursement for emergency medical imaging in the era of payment reform. The panel included representatives from the National Quality Forum and Centers for Medicare and Medicaid Services, as well as emergency physicians with expertise in quality measures and payment reform.52 The second afternoon panel included representatives from the National Institutes of Health (Office of Emergency Care Research and National Institute of Biomedical Imaging and Bioengineering), the Patient-Centered Outcomes Research Institute, and the Agency for Healthcare Research and Quality. Panelists discussed opportunities for funding at their agencies and strategies for successful grant applications.53 Perhaps the most important parts of the consensus conference were the two breakout sessions, during

Table 3 Breakout Group Demographics* Participant Specialty, n (%) Group Number

Total Participants (N)

Trainees, n (%)

EM

Radiology

1

65

10 (16)

45 (69)

7 (11)

6 (9)

2

26

4 (16)

17 (65)

1 (8)

2 (8)

3

50

6 (13)

42 (84)

2 (4)

0 (0)

4 5

36 45

7 (19) 6 (14)

28 (78) 35 (78)

4 (11) 2 (4)

3 (8) 3 (7)

6

48

8 (17)

33 (69)

6 (15)

1 (2)

164

23 (14)

118 (72)

18 (11)

9 (5)

Total†

Pediatric EM

Other, n (specialty) 1 1 2 1 1 1 1 1 3 1 1 1 1 1 1 1 1 1 2 2 1 1 1 2 1 1 1 1 1 1 1 1 1 3 2 4 2 1 1

(decision sciences) (pediatric surgery) (medical student) (radiopharmaceuticals) (CT manufacturing) (not specified) (research manager) (neurology) (health services research) (CT manufacturing) (medical physics) (patient representative) (dermatology) (medical student) (research manager) (health services research) (medical physics) (decision sciences) (research manager) (medical student) (medical student) (medical physics) (pediatric surgery) (CT manufacturing) (radiopharmaceuticals) (health services research) (not specified) (pediatric surgery) (dermatology) (neurology) (decision sciences) (patient representative) (medical physics) (health services research) (research manager) (medical student) (CT manufacturing) (radiopharmaceuticals) (not specified)

*Includes those involved in preconference planning and brainstorming and those present at the conference. †Totals do not represent sums of columns as individuals could participate in more than one group.

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which the breakout groups convened to achieve consensus on priority research questions in the six core areas. Conference participants had the opportunity to attend one of three content-specific groups in the morning and one of three groups in the afternoon. Demographics of the group participants are listed in Table 3. The group leaders for each of the six groups were tasked with summarizing the preparation performed to date, including an overview of the pertinent literature, defining critical gaps in research of that core topic, and brainstorming priority areas for further discussion. Each group, a priori, determined a process for achieving consensus within the group. The output from each of these groups is summarized in other articles in this issue.54–60

ballots of “funding dollars”) given to participants. Following the conference, group leaders collated the results of the discussions and voting and revised the preconference drafts to create final versions of the research agendas for publication.

Consensus Methodology The 2015 AEM consensus conference methodology used an iterative consensus-driven process of soliciting ideas and questions from a group of stakeholders who were brought together for each of our six core areas of emergency diagnostic imaging. The relevant stakeholders for each of the six breakout groups participated in a yearlong consensus-building process specific to the core topic of that group. The goal was to create a prioritized research agenda for emergency diagnostic imaging for each of the six defined areas. Group members initially performed topic-specific literature reviews and, with input from the relevant content experts in each group, identified current research gaps for their topic areas. Based on the research gaps found, each of the six groups identified domains, themes, and/or specific questions relevant to research in their subject matter. All of the groups used modified versions of two validated and commonly used consensus methods: the nominal group technique and the Delphi technique.61 A description of the specific methodology for each group may be found in the individual group article.54–60 An iterative process including discussion and reprioritization occurred within the groups prior to the conference day. As part of the consensus methodology, three of the groups surveyed group members electronically for further consensus development and reprioritization. The draft manuscripts outlining the prioritized research agendas were posted on the SAEM website 2 weeks prior to the conference and e-mails were sent to registered conference attendees with links to each group’s agenda. On the day of the conference, group members and conference participants gathered to further generate consensus. The individual breakout group leaders briefly reviewed background for the draft agenda and described the consensus methodology used. Within each breakout group, smaller subgroups were formed, each led by a group leader or other designated group facilitator who led a robust discussion and vetting of the proposed agenda. Additional potential research questions were solicited from conference attendees and also vetted during the meeting process. Group members then voted to prioritize the top research questions relevant to their specific topic. Voting methods included hand count and questions on flip charts and posters with a fixed number of response items (dots/stickers or

SUMMARY

Conference Participants There were 164 individuals involved in the conference (see issue appendix, p. •••), including 144 who attended at least one breakout session on the day of the conference and 20 who were unable to attend the conference, but who made significant contributions during the preconference planning. Trainees comprised 14% of conference participants, and 28% of those involved in the conference were from specialties outside of general EM.

The 2015 AEM consensus conference was a productive, multidisciplinary conference that generated a consensus-driven agenda in six key areas of emergency diagnostic imaging. We hope that the recommendations set forth by this conference lead to future research supported by funding organizations and journal editors and contribute to our optimization of emergency diagnostic imaging. References 1. Centers for Disease Control and Prevention. Quick Stats: Annual Percentage of Emergency Department Visits With Selected Imaging Tests Ordered or Provided — National Hospital Ambulatory Medical Care Survey, United States, 2001-2010. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6 222a6.htm. Accessed Sep 11, 2015. 2. Kocher KE, Meurer WJ, Fazel R, Scott PA, Krumholz HM, Nallamothu BK. National trends in use of computed tomography in the emergency department. Ann Emerg Med 2011;58:452–62. 3. Larson DB, Johnson LW, Schnell BM, Salisbury SR, Forman HP. National trends in CT use in the emergency department: 1995-2007. Radiology 2011;258:164–73. 4. Larson DB, Johnson LW, Schnell BM, Goske MJ, Salisbury SR, Forman HP. Rising use of CT in child visits to the emergency department in the United States, 1995-2008. Radiology 2011;259:793–801. 5. Arasu VA, Abujudeh HH, Biddinger PD, et al. Diagnostic emergency imaging utilization at an academic trauma center from 1996 to 2012. J Am Coll Radiol 2015;12:467–74. 6. Hamra GB, Semelka RC, Burke LM, Pate V, Brookhart MA. Trends in diagnostic CT among fee-forservice enrollees, 2000-2011. J Am Coll Radiol 2014;11:125–30. 7. Raja AS, Ip IK, Sodickson AD, et al. Radiology utilization in the emergency department: trends of the past 2 decades. Am J Roentgen 2014;203:355–60. 8. Miglioretti DL, Johnson E, Williams A, et al. The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatr 2013;167:700–7.

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9. Marchione M. CT Scans Pose Risks, Need More Regulation. Available at: http://www.huffingtonpost.com/2010/06/24/ct-scans-pose-risksneed_n_623934.html. Accessed Sep 11, 2015 10. Dunnick NR, Applegate KE, Arenson RL. The inappropriate use of imaging studies: a report of the 2004 Intersociety Conference. J Am Coll Radiol 2005;2:401–6. 11. Food and Drug Administration. White Paper: Initiative to Reduce Unnecessary Radiation Exposure From Medical Imaging. Available at: http://www.fda. gov/Radiation-EmittingProducts/RadiationSafety/Radi ationDoseReduction/ucm199994.htm. Accessed Sep 11, 2015. 12. National Quality Forum. National Voluntary Consensus Standards for Imaging Efficiency: A Consensus Report. Available at: http://www.qualityforum. org/Publications/2012/01/National_Voluntary_Consen sus_Standards_for_Imaging_Efficiency__A_Consensus_ Report.aspx. Accessed Sep 11, 2015. 13. Kanzaria HK, Hoffman JR, Probst MA, Caloyeras JP, Berry SH, Brook RH. Emergency physician perceptions of medically unnecessary advanced diagnostic imaging. Acad Emerg Med 2015;22:390–8. 14. Thompson D. Malpractice Fears Spurring Most ER Docs to Order Unnecessary Tests. Available at: http://health.usnews.com/health-news/articles/2015/ 03/24/malpractice-fears-spurring-most-er-docs-to-or der-unnecessary-tests. Accessed Sep 11, 2015. 15. Park A. Your Doctor Likely Orders More Tests Than You Actually Need. Available at: http://time.com/ 3754900/doctors-unnecessary-tests/. Accessed Sep 11, 2015. 16. HealthDay. Majority of ER Doctors Admit Ordering Tests Defensively. Available at: http://www.doctorslounge.com/index.php/news/pb/53958. Accessed Sep 11, 2015. 17. Yong PL, Saunders RS, Olsen L (editors). The Healthcare Imperative: Lowering Costs and Improving Outcomes – Workshop Series Summary. Available at: http://www.iom.edu/Reports/2011/The-Health care-Imperative-Lowering-Costs-and-Improving-Out comes.aspx. Accessed Sep 11, 2015. 18. Crichlow A, Cuker A, Mills AM. Overuse of computed tomography pulmonary angiography in the evaluation of patients with suspected pulmonary embolism in the emergency department. Acad Emerg Med 2012;19:1219–26. 19. Gottlieb RH, La TC, Erturk EN, et al. CT in detecting urinary tract calculi: influence on patient imaging and clinical outcomes. Radiology 2002;225:441–9. 20. Korley FK, Pham JC, Kirsch TD. Use of advanced radiology during visits to US emergency departments for injury-related conditions, 1998-2007. JAMA 2010;304:1465–71. 21. Burge AJ, Freeman KD, Klapper PJ, Haramati LB. Increased diagnosis of pulmonary embolism without a corresponding decline in mortality during the CT era. Clin Radiol 2008;63:381–6. 22. Goldstone A, Bushnell A. Does diagnosis change as a result of repeat renal colic computed tomography scan in patients with a history of kidney stones? Am J Emerg Med 2010;28:291–5.

23. Schroeder AR, Redberg RF. The harm in looking. JAMA Pediatr 2013;167:693–5. 24. Mills AM, Raja AS, Marin JR. Optimizing diagnostic imaging in the emergency department. Acad Emerg Med 2015;22:625–31. 25. Hess EP, Marin J, Mills A. Medically unnecessary advanced diagnostic imaging and shared decisionmaking in the emergency department: opportunities for future research. Acad Emerg Med 2015;22:475– 7. 26. Overkill GA. The New Yorker. Available at: http:// www.newyorker.com/magazine/2015/05/11/overkillatul-gawande. Accessed Sep 11, 2015. 27. Kocher KE, Meurer WJ, Desmond JS, Nallamothu BK. Effect of testing and treatment on emergency department length of stay using a national database. Acad Emerg Med 2012;19:525–34. 28. Newman-Toker DE, McDonald KM, Meltzer DO, et al. How much diagnostic safety can we afford, and how should we decide? A health economics perspective. BMJ Qual Safe 2013;22(Suppl 2):ii11–20. 29. Samim M, Goss S, Luty S, Weinreb J, Moore C. Incidental findings on CT for suspected renal colic in emergency department patients: prevalence and types in 5,383 consecutive examinations. J Am Coll Radiol 2015;12:63–9. 30. Perelas A, Dimou A, Saenz A, et al. Incidental findings on computed tomography angiography in patients evaluated for pulmonary embolism. Ann Am Thorac Soc 2015;12:689–95. 31. Kelly ME, Heeney A, Redmond CE, et al. Incidental findings detected on emergency abdominal CT scans: a 1-year review. Abdom Imaging 2015;40:1853–7. 32. Sierink JC, Saltzherr TP, Russchen MJ, et al. Incidental findings on total-body CT scans in trauma patients. Injury 2014;45:840–4. 33. Mitchell AM, Jones AE, Tumlin JA, Kline JA. Immediate complications of intravenous contrast for computed tomography imaging in the outpatient setting are rare. Acad Emerg Med 2011;18:1005–9. 34. Mitchell AM, Jones AE, Tumlin JA, Kline JA. Prospective study of the incidence of contrastinduced nephropathy among patients evaluated for pulmonary embolism by contrast-enhanced computed tomography. Acad Emerg Med 2012;19:618– 25. 35. Centers for Medicare and Medicaid Services. Hospital Value-Based Purchasing. Available at: http://www. cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/ index.html. Accessed Sep 11, 2015. 36. National Council on Radiation Protection and Measurements. NCRP Report 160: Ionizing Radiation Exposure of the Population of the United States. Available at: https://rpop.iaea.org/RPOP/RPoP/Con tent/ArchivedNews/NCRP-report-160.htm. Accessed Sep 11, 2015. 37. Pearce MS, Salotti JA, Little MP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet 2012;380:499–505. 38. Mathews JD, Forsythe AV, Brady Z, et al. Cancer risk in 680 000 people exposed to computed

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40.

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48.

49.

50.

51.

52.

tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ 2013;346:f2360. Redberg RF, Smith-Bindman R. We Are Giving Ourselves Cancer. New York Times. Available at: http://www.nytimes.com/2014/01/31/opinion/we-aregiving-ourselves-cancer.html?hp&rref=opinion&_r=1. Accessed Sep 11, 2015. Sataline S. Doctors May Risk Overuse of CT Scans. Wall Street Journal. Available at: http://online.wsj. com/article/SB119627836509306828.html. Accessed Sep 11, 2015. Wang SS. CT Scans on Children Worry Experts. Wall Street Journal. Available at: http://www.wsj.com/articles/SB10001424127887324904004578537564 115192112. Accessed Sep 11, 2015. American Board of Internal Medicine. Choosing Wisely. An Initiative of the ABIM Foundation. Available at: http://www.choosingwisely.org. Accessed Sep 11, 2015. American College of Emergency Physicians. ACEP Announces List of Tests as Part of Choosing Wisely Campaign. Available at: http://www.acep.org/Clini cal—Practice-Management/ACEP-Announces-List-ofTests-As-Part-of-Choosing-Wisely-Campaign/. Accessed Sep 11, 2015. Goske MJ, Applegate KE, Boylan J, et al. The Image Gently campaign: working together to change practice. Am J Roentgen 2008;190:273–4. Alliance for Radiation in Pediatric Imaging. Image Gently Available at: http://www.imagegently.org. Accessed Sep 11, 2015. American College of Radiology. Image Wisely. Available at: http://imagewisely.org. Accessed Sep 11, 2015. Brink JA, Amis ES. Image Wisely: a campaign to increase awareness about adult radiation protection. Radiology 2010;257:601–2. Allen B Jr. Appropriate use of medical imaging shouldn’t always mean less imaging. J Am Coll Radiol 2015;12:211–2. McCabe AM, Kuppermann N. Generation of evidence and translation into practice: lessons learned and future directions. Acad Emerg Med 2015;22:1372–79. Kanzaria HK, Hall MK, Moore C, Burstin H. Emergency department diagnostic imaging: the journey to quality. Acad Emerg Med 2015;22:1380–84. Blackmore CC, Castro A. Improving the quality of imaging in the emergency department. Acad Emerg Med 2015;22:1385–92. Berdahl C, Schuur JD, Fisher N, Burstin H, Pines JM. Policy measures and reimbursement for emergency medical imaging in the era of payment

53.

54.

55.

56.

57.

58.

59.

60.

61.

1371

reform: proceedings from a panel discussion of the 2015 AEM Consensus Conference. Acad Emerg Med 2015;22:1393–99. Cherney A, Marin JR, Anise A, et al. Funding research in emergency diagnostic imaging: summary of a panel discussion at the 2015 Academic Emergency Medicine consensus conference. Acad Emerg Med 2015;22:1400–5. Finnerty NM, Rodriguez RM, Carpenter CR, et al. Clinical decision rules for diagnostic imaging in the emergency department: a research agenda. Acad Emerg Med 2015;22:1406–16. Kanzaria HK, McCabe A, Meisel Z, et al. Advancing patient-centered outcomes in emergency diagnostic imaging: a research agenda. Acad Emerg Med 2015;22:1435–46. Kuehl DR, Berdahl CT, Jackson TD, et al. Advancing the use of administrative data for emergency department diagnostic imaging research. Acad Emerg Med 2015;22:1417–26. Lewiss RE, Chan W, Sheng AY, et al. Research priorities in the utilization and interpretation of diagnostic imaging: education, assessment, and competency. Acad Emerg Med 2015;22:1447–55. Moore CL, Broder J, Gunn M, et al. Comparative effectiveness research: alternatives to “traditional” computed tomography use in the acute care setting. Acad Emerg Med 2015;22:1465–73. Probst MA, Dayan PS, Raja AS, et al. Knowledge translation and barriers to imaging optimization in the emergency department: a research agenda. Acad Emerg Med 2015;22:1455–64. Sabbatini AK, Merck LH, Froemming A, et al. Optimizing patient-centered communication and multidisciplinary care coordination in emergency diagnostic imaging: a research agenda. Acad Emerg Med 2015;22:1427–34. Fink A, Kosecoff J, Chassin M, Brook RH. Consensus methods: characteristics and guidelines for use. Am J Public Health 1984;74:979–83.

Supporting Information The following supporting information is available in the online version of this paper: Data S1. The video is in MP4 format. Please note: Wiley Periodicals Inc. is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article. Video S1. Promotional video for the 2015 Academic Emergency Medicine Consensus Conference on diagnostic imaging.