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Background -The utility of duplex venous scanning (DVS) for suspected deep vein thrombosis (DVT) in the emergency department (ED) remains controversial. Protocols for efficient use of DVS have been proposed but not universally adhered to. We aimed to measure potential cost savings and economic impact in our institution and nationally with adherence to our institutional protocol for DVS in Medicare patients seen in the ED.
Methods - We have previously described the utility of after-hours DVS in the workup of suspected DVT in our ED, have proposed an algorithm to maximize efficiency, and have calculated that 15.3% of DVS can safely be avoided with adherence to this protocol. By investigating cost variables for equipment, administrative overhead and personnel costs, the cost of performing DVS was computed. The national Medicare database was queried for number of DVS performed in the ED (HCPS 93970 or 93971) and charges/payments by Medicare were identified. We then determined the cost savings at our institution and nationally by Medicare.
Results - 2087 DVS were performed in the ED at our institution across all payers in the study period. 572 Medicare patients had 249 (43%) bilateral and 323 (57%) unilateral studies. Cost per DVS at our institution was calculated at $306.70. Annual institutional savings using the protocol were estimated at $97,710. Nationally, there were 306,307 Medicare beneficiary DVS studies through the ED in 2011. Eliminating unnecessary DVS through the ED would result in $5,285,090 savings annually.

Number of DVS scans in our ED (HCPS 93970 & 93971)	Cost of DVS scans in our ED	Number of DVS not necessary	Our potential savings	Number of DVS scans in a ED for Medicare patients nationwide	Total Medicare charges	Total paid by Medicare	Number of DVS scans for Medicare patients not necessary	Potential Savings by Medicare
2087	$640,083	319	$97,933	306,307	$275,796,852	$34,543,066	46,865	$5,285,090

Conclusion - Increasing pressure for cost containment under a value based payment model in preparation for ACOs and ‘bundled’ payments necessitates critical evaluation of resource utilization in each clinical area related to Vascular Surgery. Adherence to a protocol maximizing appropriate utilization of DVS in the ED as an example can result in significant cost savings locally, for Medicare and the taxpayer. Applying this schema nationally is an opportunity for responsible management of finite resources, reducing wasteful care and significant cost containment.