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Emergency Radiology |
1 From the Department of Radiology (J.P.M., M.S.C., C.D.J.) and Division of Emergency Medicine (J.R.R.), University of California-Davis Medical Center, Ambulatory Care Center, 4860 Y St, Ste 3100, Sacramento, CA 95817. From the 1998 RSNA scientific assembly. Received May 27, 1999; revision requested August 5; final revision received March 3, 2000; accepted March 7. Address correspondence to J.P.M. (e-mail: john.mcgahan@ucdmc.ucdavis.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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MATERIALS AND METHODS: Data for a 6-month period during which US services were provided by a sonographer on call from 11 PM to 7 AM were compared with data for a 6-month period during which a sonographer was in house during this shift.
RESULTS: With 11 PM to 7 AM on-call coverage, the sonographers performed 147 examinations in a 6-month period, an average of 0.81 examination per shift. After institution of in-house coverage for this shift, 792 US examinations were performed in 6 months, an average of 4.3 examinations per shift. The cost for 11 PM to 7 AM in-house sonographer coverage for 6 months was approximately $16,000 more than that for on-call coverage. This cost would be offset by revenues from one additional examination per night. The cost per examination for the 11 PM to 7 AM shift decreased from $124.70 to $43.33.
CONCLUSION: At the authors’ institution, 24-hour in-house sonographer coverage resulted in additional cost, which was offset by revenues from additional examinations. There was nearly a fivefold increase in the number of US examinations performed per shift. These examinations were performed more expediently, enabling more rapid patient triage.
Index terms: Cost-effectiveness • Emergency medical service system • Radiology and radiologists, departmental management • Ultrasound (US), utilization
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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While on call, the sonographer was paid 40% of the usual salary and 150% of the salary for callback US examinations. For callback examinations, sonographers were paid for a minimum of 2 hours per examination. After a night on call, sonographers were expected to work the next day. During this period we also instituted immediate sonographer response to the ED for patients with blunt abdominal trauma. We performed US examinations for these patients on a trial basis for more than a year until we had adequately assessed the utility of these examinations at our institution (8).
Because sonographers were called back more frequently for after-hours examinations and the utility of US in patients with blunt abdominal trauma was demonstrated, we instituted 24-hour in-house sonographer coverage. We rearranged sonographer coverage so that one sonographer’s schedule ended at 7 PM and night-time coverage was provided by a sonographer who worked from 7 PM to 7 AM. This shift was shared by three sonographers—two with a 0.83-time position and one with a 0.6-time position, which was equivalent to a total of 2.26 full-time employees. In a 30-day period, the two 0.83-time sonographers would typically work 11 days, and the one 0.6-time sonographer would work approximately 8 days. These sonographers would usually group workdays into 2 days of work followed by several days off. One preferred to work 4 nights consecutively.
We compared the data for extra costs (ie, added salaries), number of examinations, and total number of relative value units (RVUs) performed for (a) the 6 months before the institution of 24-hour US coverage (May 6 to October 31, 1996) and (b) a more recent 6-month period after 24-hour US coverage had been instituted (May 6 to October 31, 1998). The data analyzed included total number of examinations, total number of RVUs, and total hours of in-house coverage for each 6-month period. RVUs included both technical and professional components. We then compared these same variables for the two 6-month periods for the shift from 11 PM to 7 AM. To complete this analysis, we calculated the total number of non–on-call sonographers used, their salaries, and their call reimbursement for both time periods and performed a similar comparison between the two periods. We retrospectively reviewed the patient log for each day during both periods. After collecting this data we also were able to calculate the total sonographer cost (salaries), sonographer cost per examination, and sonographer cost per RVU for the total coverage and for the 11 PM to 7 AM coverage during each 6-month period. Sonographer salaries were calculated as the average sonographer’s salary plus benefits.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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The total number of RVUs of the examinations were calculated for each period by multiplying the total number of RVUs for each separate examination, and these findings are presented in the Table. The total non–on-call sonographer coverage was tabulated. Because we were comparing 6-month periods, we halved the total number of our sonographers in the two periods when making these calculations. For the pre–24-hour coverage, we had no in-house sonographers. For the post–24-hour coverage, we had 2.26 sonographers covering a 12-hour period, and for the 8-hour period from 11 PM to 7 AM, we used 1.5 sonographers for 1 year. Therefore, 0.75 of a full-time sonographer was used to cover this 6-month period. Salaries were calculated at the rate of $22 per hour, a total of $45,760 per year for sonographer coverage. The total call reimbursement calculations included payment to sonographers at rates of 40% of $22 for standby and 150% of $22 for each time they were called back; the $22 included wages and benefits. This calculation for 6 months before 24-hour coverage was $25,709.20 for the total coverage (weeknights and weekends) and $18,337.00 for the 11 PM to 7 AM coverage. The cost for sonographers per examination and per RVU was calculated by dividing the total sonographer cost by the total number of examinations or the RVUs for the specific time. The sonographer cost per examination showed the greatest change, from nearly $125 before 24-hour coverage to $43 after 24-hour coverage. These results are presented in the Table.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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More recently, US has been shown to be useful in detecting abdominal abnormalities in patients with blunt abdominal trauma. Once its value in such patients was established, we needed to institute a plan for performing it expediently. We decided to continue to have sonographers perform these examinations, with subsequent review by radiology residents or faculty. All examinations are reviewed either on hard copy (film) or with a picture archiving and communication system (AEGIS; Acuson, Mountain View, Calif). A response time of 5 minutes was requested for these emergency examinations, for which 24-hour in-house sonographer coverage was required. In addition, we generally have had increasing demand to perform US more expediently in our ED patient population. For instance, in patients presenting with abdominal or pelvic pain, a US examination is now performed as soon as possible rather than the next morning. Previously, if an examination was not considered to be an emergency case, the patient either was treated without the benefit of US or may have had to wait in the ED until 7 AM. Delaying US examinations prevented rapid patient triage in the ED and sometimes delayed diagnosis and treatment.
Sonographer Shift
We had initial trepidation about the willingness of sonographers to cover the 11 PM to 7 AM shift. We found, however, that several sonographers preferred this shift, which was eventually changed to a 7 PM to 7 AM shift. The advantages included the ability to share childcare responsibility with their partners and have several days off in a row with a 12-hour work schedule. Other sonographers had mixed reactions to 24-hour coverage. Some were anxious about the loss of on-call and callback revenue. One difficulty with the previous on-call system, however, was that sonographers sometimes came to work late or called in sick the day after a "rough" night on call. The institution of 24-hour in-house US relieved sonographers of these on-call responsibilities.
Hours of Coverage, Number of Examinations, and RVUs
The total hours of coverage, number of examinations, and number of RVUs were analyzed for the described 6-month periods in 1996 and 1998. These results are shown in the Table. The total number of examinations increased in this 2-year period, reflecting increased utilization of US within our hospital. Given the interval of 2 years, the causes of the increased volume are multifactorial and may include changes in the health care system and the ED volume as well as the change to 24-hour coverage. For the 11 PM to 7 AM shift, we had no in-house coverage in 1996, compared with 1,432 hours of in-house coverage in 1998. The total number of examinations increased from 147 to 792, or from 0.82 to 4.3 examinations per shift. The total number of RVUs increased from 304 to more than 2,400. The types of examinations are tabulated in the Table.
Additional Costs
Costs were analyzed and compared for the two periods. The total number of sonographer full-time employees was used in calculating sonographer salaries for the 6-month periods. We had eight sonographers for the pre–24-hour coverage and increased this number to 10.26. This was calculated as four sonographers paid $45,760 per year, or $183,040, compared with 5.13 sonographers paid a total of $234,749 as their base cost. Total call reimbursement was a calculation based on the standby cost, which was calculated for each day when the sonographers were paid at a 40% rate. When sonographers were called back, their in-house hours were not counted in the standby calculations, but rather they were multiplied by 1.5 (150%) of $22 per hour. Thus, an additional $25,709 was provided for total call reimbursement for that 6-month period, with an overall cost of $208,749. This was comparable to $234,749 for the 6-month period after in-house coverage was instituted.
Similar calculations were made for the 11 PM to 7 AM shift. There were 2.26 additional sonographers used to cover a 12-hour period from 7 PM to 7 AM. Thus, only 8 of the 12 hours were used to cover the 11 PM to 7 AM shift, or 1.5 sonographers to cover this shift for 1 year, or 0.75 sonographer to cover this shift for half a year. This would be calculated as 0.75 full-time employee times $45,760, or $34,320 for in-house sonographer coverage during this period. This was compared with the total call reimbursement from 11 PM to 7 AM, which was calculated as the standby rate of 40% of $22 plus 150% of $22 when sonographers were called back. Thus, the total sonographer cost for standby coverage for 11 PM to 7 AM was $18,337 for 6 months compared with $34,320 for in-house coverage of these hours.
We also compared sonographer cost per examination and per RVU. The sonographer cost per examination for the total time period was reduced from $37.12 per examination to $24.87. This decrease mainly reflected our increased utilization and increased productivity per sonographer for in-house coverage during the second period. Most dramatic was the sonographer cost per examination for callbacks from 11 PM to 7 AM compared with the cost for 11 AM to 7 PM in house. This cost per sonographer per examination was $124.74 for the callbacks in 1996 compared with $43.33 per examination for the in-house coverage in 1998. Although the $43.33 is still higher than the daytime cost, it is certainly a substantial decrease.
Benefits
Much of the additional cost with in-house US coverage was justified and offset by the more rapid triage and disposition of patients from the ED and the revenues from additional examinations. We believe that prompt delivery of US services also results in improved patient satisfaction. Before institution of 24-hour coverage we had some written and many verbal complaints from patients regarding the need to stay in the ED overnight to await a US examination. We have had no such complaints since the institution of 24-hour US coverage, but we did not survey patient reaction before and after institution of the 24-hour coverage.
Of the 4.3 examinations performed from 11 PM to 7 AM after the institution of 24-hour in-house coverage, some may have been performed the next morning had the on-call system still been in place. Before 24-hour coverage was instituted, many patients would wait in the ED until their US examination could be performed the next day. There is now an institutional cost savings due to more rapid triage and disposition of patients who would otherwise occupy an ED bed for up to 8 hours. Because we have a very busy ED, the need to wait for US examinations led to overcrowding in both the emergency and US departments.
Moreover, if a patient is awaiting triage on the basis of US findings, care may be delayed by 4-8 hours. This will delay the start of therapy and could affect patient outcome. For instance, delayed diagnosis of ectopic pregnancy is common and results in increased morbidity and mortality, increased blood transfusions, and cardiovascular instability (13). Unfortunately, medical history and physical examination findings do not reliably rule out ectopic pregnancy, and, therefore, emergency pelvic US is recommended in suspected cases (14).
The results of a recent study demonstrated that pelvic US performed emergently by an ED physician rather than an on-call radiology technician substantially decreased the length of stay for patients (15). The difference is due simply to more rapid performance of the US examination by in-house personnel. Likewise, it would be fair to assume that the length of stay in the ED would decrease with the use of an in-house versus an on-call sonographer. Furthermore, some patients may choose to leave the ED rather than wait; this results in a delayed or incorrect diagnosis. As a result of 24-hour coverage, patient diagnosis and disposition are faster, and, thus, beds within the ED are made available for new patients more quickly. This more rapid turnover may make it possible to see more patients. There is also an indirect cost savings to patients who would have had to miss work or pay for additional childcare while waiting in the ED overnight for their US examination. Thus, we believe patient satisfaction is improved with this prompt service. We have also had feedback from our ED physicians, who are extremely satisfied with the new availability and flexibility of US services.
We found calculating the additional revenues from additional examinations to be somewhat problematic. If, in fact, we did perform three additional examinations per shift, additional revenue would be generated. There would also be professional revenues generated from examinations and hospital revenues for this technical component of the examinations that would potentially offset the cost for additional sonographer services. Some of the patients examined were inpatients or patients from the ED hospitalized on the basis of US findings. These were usually patients in diagnosis-related groups. For other patients, there was a mixture of different potential reimbursements. Some were patients in a capitation program from whom no additional revenues could be generated. When 1998 Medicare patient provider payments are used as the technical component, however, the following reimbursement rates are obtained: for a pelvic US examination (CPT code 76856), $58.08; complete abdominal US (CPT code 76700), $75.06; and limited abdominal US (CPT code 76705), $54.00. Therefore, one additional US examination performed per shift and reimbursed at an average of these rates could generate enough revenue to offset the approximately $16,000 additional cost to the institution of providing sonographer coverage from 11 PM to 7 AM. This $16,000 is the difference between $34,320 for the in-house coverage and $18,377 for the on-call and call-back salaries before institution of 24-hour coverage. Also, in some patient groups there may be decreased utilization of less costly examinations such as CT. Although we did not study CT data during this period, there seemed to be decreased utilization of abdominal CT in patients with blunt abdominal trauma once we began using US in this setting. This analysis, however, was beyond the scope of our current study.
Twenty-four–hour in-house US coverage is provided at minimal cost to our institution and enables more rapid triage and disposition of ED patients. The cost varies from institution to institution, depending on the sonographer pay scale, the volume and frequency of callbacks, the amount the sonographer is paid for on-call coverage, and the cost for each callback. At our institution, the minimum increased cost for sonographers is potentially offset by the revenues provided by performing one additional US examination per night. More importantly, there was a decreased indirect cost to the institution as a result of more rapid triage and disposition of ED patients. Another benefit of 24-hour coverage is faster and more efficient patient care for both hospitalized patients and those admitted to the ED.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Author contributions: Guarantors of integrity of entire study, J.P.M., M.S.C.; study concepts and design, J.P.M., M.S.C.; definition of intellectual content, all authors; literature research, J.P.M., J.R.R.; clinical studies, J.P.M., M.S.C., C.D.J.; data acquisition, M.S.C.; data analysis, M.S.C., J.P.M.; statistical analysis, M.S.C.; manuscript preparation, editing, and review, all authors.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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  Y. Siegel, A. Grubstein, V. Postnikov, O. Moreh, E. Yussim, and M. Cohen Ultrasonography in Patients Without Trauma in the Emergency Department: Impact on Discharge Diagnosis J. Ultrasound Med., October 1, 2005; 24(10): 1371 - 1376. [Abstract] [Full Text] [PDF]
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 J. P. McGahan, L. Wang, and J. R. Richards From the RSNA Refresher Courses: Focused Abdominal US for Trauma RadioGraphics, October 1, 2001; 21(90001): S191 - 199. [Abstract] [Full Text] [PDF]
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