2025/03/04 by Adelene Hilbig · 1 voice
Health Professions · #Healthcare cost, quality, practices #Medical Malpractice and Liability Issues #Healthcare Quality and Management
paper · pdf · doi:10.1111/1742-6723.70013
openalex publication_date 2025/03/04 · openalex created_date 2025/03/05 · openalex updated_date 2026/07/28
At 2 AM, I ponder the positive D-dimer result for a 27-year-old woman with chest pain. Deciphering why it was ordered is impossible. It is unclear if the patient has seen a clinician prior to the blood test: no notes have been written, and the doctor front loading tests at triage has long gone home. Having now assessed the patient in question, no features on history or examination raise concern for deep vein thrombosis or pulmonary embolism (PE). Both Wells and pulmonary embolism rule-out criteria scores are negative. I contemplate the options. Ignore the result and acknowledge a PE might be missed, questionably indefensible given the history of chest pain, however un-PE like, and a positive D-dimer. Act by ordering a CT pulmonary angiogram, accepting risks associated with contrast administration, radiation, and the finding of incidentalomas and subsequent pathways this may lead down. Or defer any further decision: request a short stay bed and await the morning arrival of a senior clinician for collaborative decision making. Weighing the benefits and risks to the patient, the consequent effects of resource allocation, and the cost to the healthcare system for each option feels like an insurmountable challenge. Under increasing pressure to manage escalating ED patient presentations, ways of working have evolved with aspirations to meet key performance indciators (KPIs) focused on patient flow, frequently measured by time to be seen and length of stay (LOS) in ED. The introduction of systems utilising ED clinicians to order investigations based on rapid, limited assessments of patients at triage, under the guise of improving patient flow and thus patient care, is arguably costing us: costing patients, costing staff and costing the healthcare system. These systems facilitate increasing quantity of care delivered, perhaps even in timeframes that meet the requisite KPIs, and are associated with the beneficial streamlining of care in specific circumstances (e.g. stroke pathways). However, they do not universally encourage quality care, and it is under these circumstances, among others, that low-value care in our EDs is thriving. Encompassing care that is ineffective or offers minimal benefit, is potentially harmful, and often comes at a disproportionate cost to either the patient or the healthcare system,1 low-value care is not limited to ED, and does not just encompass over-investigation, but also treatments and interventions meeting these criteria. However, in the ED context, over-investigation has received increasing attention in recent years. The drivers of over-investigation are complex and multifactorial, and are not limited to models of care that prioritise ordering of tests at triage. Ready availability of investigations, time pressures, patient and clinician expectations, and the practice of increasingly medicolegal defensive medicine contribute,2 as does the linkage of funding to time-based KPIs. Evidence shows lower triage category patients experience increased blood tests during busier periods in EDs.3 When clinicians have less time to spend with patients, test results provide an objective data point to inform diagnoses and management decisions.4 However, laboratory testing, influenced by test turn-around time, has been demonstrated to increase ED LOS,5 thus exacerbating issues with ED overcrowding that may have precipitated testing in the first place. Testing is not risk free: in this issue of Trainee Focus, Sandler will consider incidentalomas, and the associated costs to patients and the healthcare system from investigation cascades that follow identification of benign pathology in order to eliminate the possibility of missing a potential serious diagnosis.6 Over-investigation is not just impacting patients. Junior doctors express frustration at learning emergency medicine in an environment where investigation ordering and treatment commencement at triage has negated the need for their history and examination skills, rationale investigation ordering and management decisions. When patients arrive from the waiting room with a barrage of pre-ordered tests and a formally reported CT abdomen pelvis, their role is reduced to enacting the appropriate disposition: completing the largely administrative tasks associated with discharge home or inpatient referral. In straightforward cases, for example, appendicitis, rapid assessment models may streamline patient care. However, for undifferentiated patients, the clinical course is more fraught, with premature diagnostic closure, inappropriately reassuring false negatives, or anxiety provoking false positives that contribute to further investigation cascades, all a possibility.2 Junior clinicians should not be limited to navigating the increasingly complex conversations and challenging decision making that arises from developing management plans from investigations that have often been ordered with unclear rationale based on a rapid and incomplete assessment at the front door. How do we change this trajectory? Attempts to arrest this slide have occurred. Judkins reviews the progress made by Choosing Wisely, and considers the critical role of clinician–patient communication in decisions to order investigations.7 However, big picture changes that would permit ED clinicians adequate time to perform sufficient history and examination to facilitate shared decision making and rationale investigation ordering remain aspirational at this time. Given this, what can we each, individually, do now? Keijzers will explore how deliberate clinical inertia provides clinicians with the option to pause and consider if ‘doing nothing’ may be in the best interest of the patient.8 Where low-value care has become entrenched in our EDs, Gangathimmaiah describes strategies to identify and de-implement low-value care, with a view to equipping ED clinicians to address low-value targets in their own department.9 Generally speaking, healthcare professionals working in most Australasian EDs are rarely, if ever, confronted with the devastating reality of truly finite resources in the face of infinite demand. Ethical considerations regarding utilitarian allocation of healthcare resources – fortunately – remain the remit of discussion confined to tutorial rooms in medical school. Arguably, the ready availability of testing has permitted the medical profession liberties we should not have taken. Over investigation, without thorough history and examination, has created complex expectations among medical professionals and the community around how emergency healthcare is sought, delivered and received. The system is already straining under the demand placed upon it, and it seems inevitable a time is coming in Australasia when discussions about rationing healthcare resources are no longer hypothetical. Addressing low-value care within our EDs now offers one opportunity to change this trajectory. AH is a Section Editor for Trainee Focus.