Use of Neuroimaging for Patients with Dizziness Who Present to Outpatient Clinics vs Emergency Departments in the US

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Importance: Overuse of costly neuroimaging technology is associated with low-value care for the prevalent symptom of dizziness. Although quality improvement initiatives have focused on the overuse of computed tomography (CT) scans in emergency departments (EDs), most patients with dizziness present to outpatient clinics. To inform practice and policy, a comprehensive understanding of the uses and costs of neuroimaging across settings and episodes of care is needed. Objective: To characterize neuroimaging use, timing, and spending as well as factors associated with imaging acquisition within 6 months of presentation for dizziness in outpatient vs ED settings. Design, Setting, and Participants: This cross-sectional study of commercial and Medicare Advantage claims for 805454 adults (≥18 years of age) with new diagnoses of dizziness was conducted from January 1, 2006, through December 31, 2015. Data were analyzed from October 1, 2020, to September 30, 2021. Main Outcomes and Measures: Use of neuroimaging (CT scan, magnetic resonance imaging [MRI], angiography, and ultrasonography) and total spending on neuroimaging were measured. Kaplan-Meier analysis was performed. The associations of neuroimaging with setting, sociodemographic characteristics, and clinicians were estimated with multivariable analyses. Results: A total of 805454 individuals with dizziness (502055 women [62%]; median age, 52 years [range, 18-87 years]) were included in this study; 156969 (20%) underwent neuroimaging within 6 months of presentation (65738 of 185338 [36%] presented to EDs and 91231 of 620116 [15%] presented to outpatient clinics). The median time to neuroimaging was 0 days (95% CI, 0-2 days) after ED presentation and 10 days (95% CI, 9-10 days) after outpatient presentation. Neuroimaging was independently associated with advanced age, comorbidity, race and ethnicity, ED presentation, and outpatient clinician specialty. Across sites, a head CT scan was the most used test on presentation date (92% of tests [46852 of 51022]). Within 6 months of presentation, a head CT scan was the most used test (47% of all tests [177949 of 376149]), followed by brain MRI (25% [93130 of 376149]), cerebrovascular ultrasonography (15% [56175 of 376149]), and magnetic resonance angiography (9% [34026 of 376149]). Of $88646047.03 in total neuroimaging spending, MRI accounted for 70% ($61730251.95), CT scans for 19% ($16910506.24), and ultrasonography for 11% ($10005288.84). Per-test median spending ranged from $68.97 (CT scan of the head) to $319.63 (MRI of the brain) among commercially insured individuals and $43.21 (CT scan of the head) to $362.02 (MRI of the orbit, face, and neck) among Medicare Advantage beneficiaries. Conclusions and Relevance: The findings of this cross-sectional study suggest that use of neuroimaging for dizziness is prevalent across settings. Interventions to optimize the use of neuroimaging must occur early in the patient care journey to discourage guideline-discordant use of CT scans, advocate for judicious MRI use (particularly in ambulatory settings), and account for the effects of price transparency.

Original languageEnglish (US)
Pages (from-to)465-473
Number of pages9
JournalJAMA Otolaryngology - Head and Neck Surgery
Issue number5
StatePublished - May 2022

Bibliographical note

Funding Information:
reported receiving grants from the National Institutes of Health/National Institute on Deafness and Other Communication Disorders (NIH/NIDCD) during the conduct of the study; grants from the NIH/National Institute of Neurological Disorders and Stroke, the US Department of Defense, NIH/ NIDCD, Kellogg Charitable Trust, and Lions Hearing Foundation outside the submitted work. Dr Karaca-Mandic reported receiving grants from the Agency for Healthcare Research and Quality, the American Cancer Society; personal fees from Sempre Health; and holding equity and an executive position in XanthosHealth outside the submitted work. Dr Marmor reported receiving grants from the NIH during the conduct of the study. No other disclosures were reported.

Publisher Copyright:
© 2022 American Medical Association. All rights reserved.

PubMed: MeSH publication types

  • Journal Article
  • Research Support, N.I.H., Extramural


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