Variation in use of all types of computed tomography by emergency physicians

Investigating the causes and pattern of peritoneal involvement in CT scan and comparison with ultrasound findings in peritoneal conditions: A two-center, cross-sectional study

Background and Aims

Ultrasound and computed tomography (CT) scans can be used as methods to help make a more accurate diagnosis in diseases involving the omentum and peritoneum. The present study was conducted to determine etiology and CT scan pattern of peritoneal involvement and compare it with ultrasound findings.

Methods

Patients referred to Ghaem and Imam Reza hospitals who had undergone CT scans and had involvement of peritoneum in abdominal CT scans were included in the study. The findings identified in the CT scan were recorded. According to the underlying cause determined by laparotomy or laparoscopy sample, each disease's most common pattern of involvement and types of patterns were examined. An ultrasound was conducted for every patient and the obtained information was analyzed.

Results

A total of 101 patients were included in the study, of which 61 patients (59.8%) were female and the rest were male. The most common involvement patterns in CT scans included nodular (37.6%), mixed (21.8%), and omental cake (17.8%), respectively. In 80 patients (79.2%), CT scan findings were consistent with ultrasound, but in 21 patients (20.8%), CT scan findings were not visible in ultrasound. The most common diagnoses of the patients were colorectal adenocarcinoma and gastric adenocarcinoma (20 cases, 19.8% each), followed by ovarian and uterine adenocarcinoma (19 cases, 18.8%).

Conclusion

The most common patterns of involvement of peritoneum in CT scans include nodular pattern, mix, and omental cake. The most common diseases that lead to the involvement of peritoneum are gastrointestinal cancers, uterine and ovarian cancers, and peritonitis.

Emergency physician gender and head computed tomography orders for older adults who have fallen

OBJECTIVE

Physicians vary in their computed tomography (CT) scan usage. It remains unclear how physician gender relates to clinical practice or patient outcomes. The aim of this study was to assess the association between physician gender and decision to order head CT scans for older emergency patients who had fallen.

METHODS

This was a secondary analysis of a prospective observational cohort study conducted in 11 hospital emergency departments (EDs) in Canada and the United States. The primary study enrolled patients who were 65 years and older who presented to the ED after a fall. The analysis evaluated treating physician gender adjusted for multiple clinical variables. Primary analysis used a hierarchical logistic regression model to evaluate the association between treating physician gender and the patient receiving a head CT scan. Secondary analysis reported the adjusted odds ratio (OR) for diagnosing intracranial bleeding by physician gender.

RESULTS

There were 3663 patients and 256 physicians included in the primary analysis. In the adjusted analysis, women physicians were no more likely to order a head CT than men (OR 1.26, 95% confidence interval 0.98-1.61). In the secondary analysis of 2294 patients who received a head CT, physician gender was not associated with finding a clinically important intracranial bleed.

CONCLUSIONS

There was no significant association between physician gender and ordering head CT scans for older emergency patients who had fallen. For patients where CT scans were ordered, there was no significant relationship between physician gender and the diagnosis of clinically important intracranial bleeding.

Not All Testers are Admitters: An Analysis of Emergency Physician Resource Utilization and Consultation Rates

BACKGROUND

Variability exists in emergency physician (EP) resource utilization as measured by ordering practices, rate of consultation, and propensity to admit patients.

OBJECTIVE

To validate and expand upon previous data showing that resource utilization as measured by EP ordering patterns is positively correlated with admission rates.

METHODS

This is a retrospective study of routinely gathered operational data from the ED of an urban academic tertiary care hospital. We collected individual EP data on advanced imaging, consultation, and admission rates per patient encounter. To investigate whether there might be distinct groups of practice patterns relating these 3 resources, we used a Gaussian mixture model, a classification method used to determine the likelihood of distinct subgroups within a larger population.

RESULTS

Our Gaussian mixture model revealed 3 distinct groups of EPs based on their ordering practices. The largest group is characterized by a homogenous pattern of neither high or low resource utilization (n = 37, 27% female, median years' experience: 6 [interquartile ratio {IQR} 3-18]; rates of advanced imaging, 38.9%; consultation, 45.1%; and admission 39.3%), with a modest group of low-resource users (n = 15, 60% female, median years' experience: 6 [IQR 5-14]; rates of advanced imaging, 37%; consultation, 42.6%; and admission 37.3%), and far fewer members of a high-resource use group (n = 6, 0% female, median years' experience: 6 [IQR 4-16]; rates of advanced imaging, 42.2%; consultation, 45.8%; and admission 40.6%). This variation suggests that not "all testers are admitters," but that there exist wider practice variations among EPs.

CONCLUSIONS

At our academic tertiary center, 3 distinct subgroups of EP ordering practices exist based on consultation rates, advanced imaging use, and propensity to admit a patient. These data validate previous work showing that resource utilization and admission rates are related, while demonstrating that more nuanced patterns of EP ordering practices exist. Further investigation is needed to understand the impact of EP characteristics and behavior on throughput and quality of care. © 2022 Elsevier Inc.

Clinical Decision Rules in the Evaluation and Management of Adult Gastrointestinal Emergencies

Although abdominal pain is a common chief complaint in the emergency department, only 1 in 6 patients with abdominal pain are diagnosed with a gastrointestinal (GI) emergency. These patients often undergo extensive testing as well as hospitalizations to rule out an acute GI emergency and there is evidence that not all patients benefit from such management. Several clinical decision rules (CDRs) have been developed for the diagnosis and management of patients with suspected acute appendicitis and upper GI bleeding to identify those patients who may safely forgo further testing or hospital admission. Further validation studies demonstrating the superiority of these CDRs over contemporary practice are needed.

Accuracy of emergency physicians' self-estimates of CT scan utilization and its potential effect on an audit and feedback intervention: a randomized trial

BACKGROUND

Audit and feedback (A&F) has been used as a strategy to modify clinician behavior with moderate success. Although A&F is theorized to work by improving the accuracy of clinicians' estimates of their own behavior, few interventions have included assessment of clinicians' estimates at baseline to examine whether they account for intervention success or failure. We tested an A&F intervention to reduce computed tomography (CT) ordering by emergency physicians, while also examining the physicians' baseline estimates of their own behavior compared to peers.

METHODS

Our study was a prospective, multi-site, 20-month, randomized trial to examine the effect of an A&F intervention on CT ordering rates, overall and by test subtype. From the electronic health record, we obtained 12 months of baseline CT ordering per 100 patients treated for every physician from four emergency departments. Those who were randomized to receive A&F were shown a de-identified graph of the group's baseline CT utilization, asked to estimate wherein the distribution of their own CT order practices fell, and then shown their actual performance. All participants also received a brief educational intervention. CT ordering rates were collected for all physicians for 6 months after the intervention. Pre-post ordering rates were compared using independent and repeated measures t tests.

RESULTS

Fifty-one of 52 eligible physicians participated. The mean CT ordering rate increased significantly in both experimental conditions after the intervention (intervention pre = 35.7, post = 40.3, t = 4.13, p < 0.001; control pre = 33.9, post = 38.9, t = 3.94, p = 0.001), with no significant between-group difference observed at follow-up (t = 0.43, p = 0.67). Within the intervention group, physicians had poor accuracy in estimating their own ordering behavior at baseline: most overestimated and all guessed that they were in the upper half of the distribution of their peers. CT ordering increased regardless of self-estimate accuracy.

CONCLUSIONS

Our A&F intervention failed to reduce physician CT ordering: our feedback to the physicians showed most of them that they had overestimated their CT ordering behavior, and they were therefore unlikely to reduce it as a result. After "audit," it may be prudent to assess baseline clinician awareness of behavior before moving toward a feedback intervention.

The Role of Abdominal and Pelvic Computed Tomography Scans for Geriatric Blunt Trauma Patients on Antiplatelet and/or Anticoagulation Medications

Blunt trauma is the most common mechanism of injury in the geriatric population. The benefits of computed tomography (CT) scanning have demonstrated improved outcomes for blunt trauma patients with head injuries. The purpose of our study is to evaluate the clinical value of using a CT scan of the abdomen and pelvis on geriatric blunt trauma patients on antiplatelet/anticoagulation (AP/AC) therapy. A retrospective study reviewing geriatric patients admitted to our urban level 1 trauma center from December 2012 to September 2014 was performed. The inclusion criteria for the study included patients older than 65 years of age, admission after a blunt trauma, and on AP/AC therapy. Male and female patients with dementia were more likely to have a CT scan of the abdomen and pelvis (P = 0.002 and P = 1 × 10−6, respectively). There was no statistical significance in the difference in outcomes between the demented patients who received a CT scan of the abdomen and pelvis and the ones who did not. Our study demonstrated that there is no benefit in terms of length of stay, morbidity, or mortality, regardless of sex, after a CT scan of the abdomen and pelvis.

Appropriate CT cervical spine utilisation in the emergency department

Introduction

Over 40 000 CT scans are performed in our emergency department (ED) annually and utilisation is over 80% capacity. Improving medical appropriateness of CT scans may reduce total number of scans, time, cost and radiation exposure.

Methods

Lean Six Sigma methodology was used to improve the process. A National Emergency X-Radiography Utilisation Study (NEXUS)-based PowerForm was implemented in the electronic health record and providers were educated on the criteria.

Results

The rate of potentially medically inappropriate CT C-spine scans decreased from 45% (19/42) to 22% (90/403) (two-proportion test, p=0.002). After the intervention, there was no longer a difference between midlevel providers and physicians in the rate of medically inappropriate orders (19% vs 22%) (two-proportion test, p=0.850) compared with that before the intervention (56% vs 31%) (two-proportion test, p<0.01). Overall rates of CT C-spine scans ordered decreased from 69.3 to 62.6/week (t-test, p=0.019).

Conclusion

A validated clinical decision-making tool implemented into the medical record can improve quality of care. This study lays a foundation for other imaging studies with validated support tools with similar potential improvements.

Methods to detect inappropriate use of MRI and CT for musculoskeletal conditions: A scoping review

OBJECTIVE

Identify and evaluate methods suitable for detecting inappropriate use of MRI or CT in the musculoskeletal system.

DESIGN

Systematic review of studies that described methods to measure inappropriate use of MRI or CT in the musculoskeletal system. We used a multi-step strategy to classify identified methods into categories. These categories were then analyzed according to the data needed and their limitations.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

English or German language studies that measured inappropriate use of MRI or CT in the musculoskeletal system. Articles were also included if they reported a general approach to the measurement of inappropriate imaging regardless of body region. Expert opinions, unsystematic reviews, commentaries, articles without abstracts, and studies on cancer were excluded.

RESULTS

47 studies met the inclusion criteria. The categorization of the studies resulted in seven individual approaches to measure inappropriate use: (1) availability of meaningful diagnostic information; (2) predictors associated with imaging use; (3) comparison with guideline recommendations; (4) assessment by experts; (5) comparison or analysis of patients' paths; (6) comparison with surgery findings; (7) geographic variation. All these approaches have specific data requirements and individual advantages and disadvantages regarding risk of bias and needed data.

CONCLUSIONS

We could not find a single method of choice to detect inappropriate use of MRI or CT in the musculoskeletal system. A combination of different approaches is the preferred strategy to deal with the advantages and disadvantages of the individual methods.

Emergency Department Computed Tomography Use for Non-traumatic Abdominal Pain: Minimal Variability

Introduction

Variability in the use of computed tomography (CT) between providers in the emergency department (ED) suggests that CT is ordered on a provider rather than a patient level. We aimed to evaluate the variability of CT ordering practices for non-traumatic abdominal pain (NTAP) across physicians in the ED using patient-visit and physician-level factors.

Methods

We conducted a retrospective study among 6,409 ED visits for NTAP from January 1 to December 31, 2012, at a large, urban, academic, tertiary-care hospital. We used a two-level hierarchical logistic regression model to estimate inter-physician variation. Intraclass correlation coefficient (ICC) was calculated.

Results

The hierarchical logistic regression analyses showed that patient-visit factors including younger age, arrival mode by ambulance, prior CT, >79 ED arrivals in the previous four hours, and ultrasound had statistically significant negative associations with physician CT ordering, while surgical team admission and white blood count (WBC) >12.5 K/millimeter cubed (mm³) had statistically significant positive associations with physician CT ordering. With physician-level factors, only physicians with >21 years experience after medical school graduation showed statistical significance negatively associated with physician CT ordering. Our data demonstrated increased CT ordering from the mean in only one out of 43 providers (2.3%), which indicated limited variation across physicians to order CT. After adjusting for patient-visit and physician-level factors, the calculated ICC was 1.46%.

Conclusion

We found minimal physician variability in CT ordering practices for NTAP. Patient-visit factors such as age, arrival mode, admission team, prior CT, ED arrivals in previous four hours, ultrasound, and WBC count were found to largely influence CT ordering practices.

Are testers also admitters? Comparing emergency physician resource utilization and admitting practices

OBJECTIVE

To describe the relationship between emergency department resource utilization and admission rate at the level of the individual physician.

METHODS

Retrospective observational study of physician resource utilization and admitting data at two emergency departments. We calculated observed to expected (O/E) ratios for four measures of resource utilization (intravenous medications and fluids, laboratory testing, plain radiographs, and advanced imaging studies) as well as for admission rate. Expected values reflect adjustment for patient- and time-based variables. We compared O/E ratios for each type of resource utilization to the O/E ratio for admission for each provider. We report degree of correlation (slope of the trendline) and strength of correlation (adjusted R² value) for each association, as well as categorical results after clustering physicians based on the relationship of resource utilization to admission rate.

RESULTS

There were statistically significant positive correlations between resource utilization and physician admission rate. Physicians with lower resource utilization rates were more likely to have lower admission rates, and those with higher resource utilization rates were more likely to have higher admission rates.

CONCLUSIONS

In a two-facility study, emergency physician resource utilization and admission rate were positively correlated: those who used more ED resources also tended to admit more patients. These results add to a growing understanding of emergency physician variability.

The Impact of Risk Standardization on Variation in CT Use and Emergency Physician Profiling

OBJECTIVE

The purpose of this study is to use detailed electronic health record data to profile the use of condition-specific, risk-standardized imaging by emergency physicians.

MATERIALS AND METHODS

CT utilization in four emergency departments in a single health care system was retrospectively analyzed. The primary outcome for analysis was indication-specific, risk-standardized CT utilization. We constructed seven clinical cohorts on the basis of the presence or absence of a traumatic indication for the most frequently performed CT studies. Risk standardization was performed using machine learning algorithms and hierarchic logistic regression models. Variation in CT utilization for each cohort was analyzed using coefficients of variation and box plots, the effect of risk standardization on physician profiling was determined using slope diagrams and kappa values, and within-physician correlation was assessed using correlation coefficients and matrices.

RESULTS

For the seven cohorts, the number of physicians ordering more than 25 CT studies for a particular indication ranged from 70 to 88, and the number of ED visits ranged from 17,458 to 117,489. The unadjusted variation was large for each indication (coefficient of variation, 30.2-57.9). Risk standardization resulted in reduced but persistent variation for all indications (coefficient of variation, 12.3-22.3). Among indication-specific models, risk standardization resulted in reclassification by two or more deciles for 14.0-39.1% of physicians. The R value for within-physician correlation varied from 0.02 to 0.80 and was highest between chest and abdominal imaging for trauma.

CONCLUSION

In this multisite study of CT utilization, risk standardization had a substantial impact on variation in CT utilization and emergency physician profiling. Administrators and payers should include risk standardization in future measures of physician imaging to ensure valid assessment of performance and achieve improvements in emergency care value.

Improving perceptions of empathy in patients undergoing low-yield computerized tomographic imaging in the emergency department

OBJECTIVE

We assessed emergency department (ED) patient perceptions of how physicians can improve their language to determine patient preferences for 11 phrases to enhance physician empathy toward the goal of reducing low-value advanced imaging.

METHODS

Multi-center survey study of low-risk ED patients undergoing computerized tomography (CT) scanning.

RESULTS

We enroled 305 participants across nine sites. The statement "I have carefully considered what you told me about what brought you here today" was most frequently rated as important (88%). The statement "I have thought about the cost of your medical care to you today" was least frequently rated as important (59%). Participants preferred statements indicating physicians had considered their "vital signs and physical examination" (86%), "past medical history" (84%), and "what prior research tells me about your condition" (79%). Participants also valued statements conveying risks of testing, including potential kidney injury (78%) and radiation (77%).

CONCLUSION

The majority of phrases were identified as important. Participants preferred statements conveying cognitive reassurance, medical knowledge and risks of testing.

PRACTICE IMPLICATIONS

Our findings suggest specific phrases have the potential to enhance ED patient perceptions of physician empathy. Further research is needed to determine whether statements to convey empathy affect diagnostic testing rates.

Access to primary care and computed tomography use in the emergency department

Background

The decision to obtain a computed tomography CT scan in the emergency department (ED) is complex, including a consideration of the risk posed by the test itself weighed against the importance of obtaining the result. In patients with limited access to primary care follow up the consequences of not making a diagnosis may be greater than for patients with ready access to primary care, impacting diagnostic reasoning. We set out to determine if there is an association between CT utilization in the ED and patient access to primary care.

Methods

We performed a cross-sectional study of all ED visits in which a CT scan was obtained between 2003 and 2012 at an academic, tertiary-care center. Data were abstracted from the electronic medical record and administrative databases and included type of CT obtained, demographics, comorbidities, and access to a local primary care provider (PCP). CT utilization rates were determined per 1000 patients.

Results

A total of 595,895 ED visits, including 98,001 visits in which a CT was obtained (16.4%) were included. Patients with an assigned PCP accounted for 55% of all visits. Overall, CT use per 1000 ED visits increased from 142.0 in 2003 to 169.2 in 2012 (p < 0.001), while the number of annual ED visits remained stable. CT use per 1000 ED visits increased from 169.4 to 205.8 over the 10-year period for patients without a PCP and from 118.9 to 142.0 for patients with a PCP. Patients without a PCP were more likely to have a CT performed compared to those with a PCP (OR 1.57, 95%CI 1.54 to 1.58; p < 0.001). After adjusting for age, gender, year of visit and number of comorbidities, patients without a PCP were more likely to have a CT performed (OR 1.20, 95% CI 1.18 to 1.21, p < 0.001).

Conclusions

The overall rate of CT utilization in the ED increased over the past 10 years. CT utilization was significantly higher among patients without a PCP. Increased availability of primary care, particularly for follow-up from the ED, could reduce CT utilization and therefore decrease costs, ED lengths of stay, and radiation exposure.

Addressing overuse in emergency medicine: evidence of a role for greater patient engagement

Overuse of health care refers to tests, treatments, and even health care settings when used in circumstances where they are unlikely to help. Overuse is not only wasteful, it threatens patient safety by exposing patients to a greater chance of harm than benefit. It is a widespread problem and has proved resistant to change. Overuse of diagnostic testing is a particular problem in emergency medicine. Emergency physicians cite fear of missing a diagnosis, fear of law suits, and perceived patient expectations as key contributors. However, physicians' assumptions about what patients expect are often wrong, and overlook two of patients' most consistently voiced priorities: communication and empathy. Evidence indicates that patients who are more fully informed and engaged in their care often opt for less aggressive approaches. Shared decision making refers to (1) providing balanced information so that patients understand their options and the trade-offs involved, (2) encouraging them to voice their preferences and values, and (3) engaging them-to the extent appropriate or desired-in decision making. By adopting this approach to discretionary decision making, physicians are better positioned to address patients' concerns without the use of tests and treatments patients neither need nor value.

Factors associated with imaging overuse in the emergency department: A systematic review

BACKGROUND

Emergency departments (ED) are sites of prevalent imaging overuse; however, determinants that drive imaging in this setting are not well-characterized. We systematically reviewed the literature to summarize the determinants of imaging overuse in the ED.

METHODS

We searched MEDLINE® and Embase® from January 1998 to March 2017. Studies were included if they were written in English, contained original data, pertained to a U.S. population, and identified a determinant associated with overuse of imaging in the ED.

RESULTS

Twenty relevant studies were included. Fourteen evaluated computerized tomography (CT) scanning in patents presenting to a regional ED who were then transferred to a level 1 trauma center; incomplete transfer of data and poor image quality were the most frequently described reasons for repeat scanning. Unnecessary pre-transfer scanning or repeated scanning after transfer, in multiple studies, was highest among older patients, those with higher Injury Severity Scores (ISS) and those being transferred further. Six studies explored determinants of overused imaging in the ED in varied conditions, with overuse greater in older patients and those having more comorbid diseases. Defensive imaging reportedly influenced physician behavior. Less integration of services across the health system also predisposed to overuse of imaging.

CONCLUSIONS

The literature is heterogeneous with surprisingly few studies of determinants of imaging in minor head injury or of spine imaging. Older patient age and higher ISS were the most consistently associated with ED imaging overuse. This review highlights the need for precise definitions of overuse of imaging in the ED.

Self-awareness of computed tomography ordering in the emergency department

OBJECTIVES

Physician variation in the use of computed tomography (CT) is concerning due to the risks of ionizing radiation, cost, and downstream effects of unnecessary testing. The objectives of this study were to describe variation in CT-ordering rates among emergency physicians (EPs), to measure correlation between perceived and actual CT-ordering rates, to assess attitudes that influence decisions to order imaging tests, and to identify EP attitudes associated with higher CT utilization.

METHODS

This study was a retrospective review of imaging and administrative billing records at two emergency department sites of a tertiary care adult teaching hospital. The study also included a cross-sectional survey of EPs at this hospital. We asked physicians about their perceived ordering behaviour, and what factors influenced their decision to order a CT. We examined correlations between perceived and actual CT-ordering rates. We adjusted ordering rates for shift distribution using a logistic regression model and identified outlier physicians whose ordering rate was significantly lower or higher than expected. We used multivariable regression analysis to determine which survey responses predicted higher CT utilization.

RESULTS

During the study period, 59 EPs saw 45,854 patients, and ordered 6,609 CTs - a mean ordering rate of 14.4% (standard deviation (SD)=4.3%). The ordering rate for individual physicians ranged from 5.9% to 25.9%. Of the 59 EPs, 13 EPs were low-ordering outliers; 12 were high-ordering outliers. Forty-five EPs (76.3%) completed the survey. Mean perceived ordering rate was 12.6%, and was weakly correlated with actual ordering (r=0.19, p=0.21). 42 EPs (93.3%) believed they ordered "about the same" or "fewer" CTs than their peers. Of the 17 EPs in the two highest ordering quintiles, only 3 (18%) knew they were high orderers. In the multivariable analysis, higher ordering was associated with increasing strength of response to the following predictors: medico-legal risk (relative risk [RR]=1.18, 95% CI: 1.03-1.21), risk of contrast (RR=1.14, 95% CI: 1.07-1.22), what colleagues would do (RR=1.09, 95% CI: 0.99-1.19), risk of missing a diagnosis (RR=1.08, 95% CI: 0.98-1.21), and patient wishes (RR=1.07, 95% CI: 0.97-1.17).

CONCLUSIONS

There is large variation in CT ordering among EPs. Physicians' self-reported ordering rate correlates poorly with actual ordering. High CT orderers were rarely aware that they ordered more than their colleagues. Higher rates of ordering were observed among physicians who reported increased concern with 1) risk of missing a diagnosis, 2) medico-legal risk, 3) risk of contrast, 4) patient wishes, and 5) what colleagues would do.

Emergency Physician Knowledge, Attitudes, and Behavior Regarding ACEP's Choosing Wisely Recommendations: A Survey Study

OBJECTIVE

In 2013, the American College of Emergency Physicians joined the Choosing Wisely campaign; however, its impact on emergency physician behavior is unknown. We assessed knowledge, attitudes, and self-reported behaviors regarding the Choosing Wisely recommendations.

METHODS

We performed a cross-sectional survey of emergency physicians at a national meeting. We approached 819 physicians; 765 (93.4%) completed the survey.

RESULTS

As a result of the Choosing Wisely campaign, most respondents (64.5%) felt more comfortable discussing low-value services with patients, 54.5% reported reducing utilization, and 52.5% were aware of local efforts to promote the campaign. A majority (62.97%) of respondents were able to identify at least four of five recommendations. The most prevalent low-value practices were computed tomography (CT) brain for minor head injury (29.9%) and antibiotics for acute sinusitis (26.9%). Few respondents reported performing lumbar radiograph for nontraumatic low back pain (7.8%) and Foley catheter for patients who can void (5.6%). Respondents reported patient/family expectations as the most important reason for ordering antibiotics for sinusitis (68%) and imaging for low back pain (56.8%). However, concern for serious diagnosis was the most important reason for performing CT chest for patients with normal D-dimer (49.7%) and CT abdomen for recurrent uncomplicated renal colic (42.5%). A minority (3.8% to 26.7%) of respondents identified malpractice risk as the primary reason for performing low-value services.

CONCLUSIONS

Despite familiarity with Choosing Wisely, many emergency physicians report performing low-value services. Primary reasons for low-value services differ: antibiotic prescribing was driven by patient/family expectations, while concern for serious diagnosis influenced advanced diagnostic imaging. Greater efforts are needed to promote effective dissemination and implementation; such efforts may be targeted based on differing reasons for low-value services.

Variation in Computed Tomography Use for Evaluation of Head Injury in a Pediatric Emergency Department

OBJECTIVES

Recent research has shown significant variation in rates of computed tomography (CT) use among pediatric hospital emergency departments (ED) for evaluation of head injured children. We examined the rates of CT use by individual ED attending physicians for evaluation of head injured children in a pediatric hospital ED.

METHODS

We used an administrative database to identify children younger than 18 years evaluated for head injury from January 2011 through March 2013 at our children's hospital ED, staffed by pediatric emergency medicine (PEM) fellowship trained physicians and pediatricians. We excluded encounters with trauma team activation or previous head CT performed elsewhere. We excluded physicians whose patient volume was less than 1 standard deviation below the group mean.

RESULTS

After exclusions, we evaluated 5340 encounters for head injury by 27 ED attending physicians. For individual physicians, CT rates ranged from 12.4% to 37.3%, with a mean group rate of 28.4%. Individual PEM physician CT rates ranged from 18.9% to 37.3%, versus 12.4% to 31.8% for pediatricians. Of the 1518 encounters in which CT was done, 128 (8.4%) had a traumatic brain injury on CT, and 125 (8.2%) had a simple skull fracture without traumatic brain injury on CT. Patient factors associated with CT use included age younger than 2 years, higher triage acuity, arrival time of 10:00 PM to 6:00 AM, hospital admission, and evaluation by a PEM physician.

CONCLUSIONS

Physicians at our pediatric hospital ED varied in the use of CT for the evaluation of head-injured children.

Incidental findings on whole-body trauma computed tomography: Experience at a major trauma centre

INTRODUCTION

The use of total-body computed tomography (CT) scanning in the evaluation of multiply injured patients is increasing, and their liberal use has stirred debate as to the added benefit relative to the risk of radiation exposure and inappropriate use of limited healthcare resources. Findings unrelated to the clinician's reasons for requesting the radiological examination are often uncovered due to the comprehensive nature of the evaluation at a trauma centre. However, some of these findings are outside the expertise of the trauma team who initially organised the scan and this may lead to uncertainty over who is best qualified to follow-up the incidental finding. We aim to evaluate the frequency of incidental findings on whole body trauma CT scans in a consecutive series of trauma admissions to our unit.

MATERIALS AND METHODS

We identified 104 consecutive major trauma patients who received a whole-body trauma CT (head, cervical spine, chest, abdomen and pelvis) from Jan 2013 to Dec 2013 in our unit (out of a total of 976 trauma admissions in the same year). Patient-specific information was extracted from computerised hospital databases containing admission and progress notes, radiological reports, operation notes and pathology reports.

RESULTS

57 patients (54.8%) had incidental findings identified on the radiologist report, with a total of 114 individual incidental findings. 6 (5.8%) patients had potentially severe findings that required further diagnostic work up; 65 (62.5%) patients had diagnostic workup dependant on their symptoms, and 43 (41.3%) patients had incidental findings of minor concern which required no follow up.

DISCUSSION AND CONCLUSIONS

Our findings reflect the literature noting that incidental findings are increasingly common due to the central diagnostic role of CT imaging in trauma care, but also due to advances in imaging techniques and quality. In keeping with published literature, we note that increased age is associated with an increased incidence of "incidental findings" and this will continue to rise with the ageing population and the mandatory nature of trauma CTs.

Incidental findings detected on emergency abdominal CT scans: a 1-year review

INTRODUCTION

In recent years, there has been a substantial rise in the use of computed tomography (CT) in the emergency medicine setting. Accordingly, with increased CT usage there has been an upsurge in incidental pathology detection.

METHODS

A retrospective review of all emergency CT abdominal scans performed at a university teaching hospital was examined. The frequency of incidental findings, their clinical significance and workload effect for the radiology department was assessed.

RESULTS

1155 patients had an emergency abdominal CT scan of which 700 had incidental findings detected. Of the incidental findings, 143 were deemed indeterminate requiring urgent investigations. Twenty-four occult neoplasms were confirmed subsequently. Additionally, 259 patients were recommended for additional diagnostics. The cumulative effect of the initial emergency abdominal CT was 15,015 relative value units (RVU). Subsequent imaging of incidental findings resulted in another 1674 RVU workload for radiology.

CONCLUSION

Incidental findings cause considerable debate and concern over which patients require significant follow-up, investigations, and/or surveillance. This exerts significant pressures on sub-specialties for their expert input, with increased workload and implications on healthcare service provision.

Clinical Decision Rules for Diagnostic Imaging in the Emergency Department: A Research Agenda

BACKGROUND

Major gaps persist in the development, validation, and implementation of clinical decision rules (CDRs) for diagnostic imaging.

OBJECTIVES

The objective of this working group and article was to generate a consensus-based research agenda for the development and implementation of CDRs for diagnostic imaging in the emergency department (ED).

METHODS

The authors followed consensus methodology, as outlined by the journal Academic Emergency Medicine (AEM), combining literature review, electronic surveys, telephonic communications, and a modified nominal group technique. Final discussions occurred in person at the 2015 AEM consensus conference.

RESULTS

A research agenda was developed, prioritizing the following questions: 1) what are the optimal methods to justify the derivation and validation of diagnostic imaging CDRs, 2) what level of evidence is required before disseminating CDRs for widespread implementation, 3) what defines a successful CDR, 4) how should investigators best compare CDRs to clinical judgment, and 5) what disease states are amenable (and highest priority) to development of CDRs for diagnostic imaging in the ED?

CONCLUSIONS

The concepts discussed herein demonstrate the need for further research on CDR development and implementation regarding diagnostic imaging in the ED. Addressing this research agenda should have direct applicability to patients, clinicians, and health care systems.

Advancing the Use of Administrative Data for Emergency Department Diagnostic Imaging Research

Administrative data are critical to describing patterns of use, cost, and appropriateness of imaging in emergency care. These data encompass a range of source materials that have been collected primarily for a nonresearch use: documenting clinical care (e.g., medical records), administering care (e.g., picture archiving and communication systems), or financial transactions (e.g., insurance claims). These data have served as the foundation for large, descriptive studies that have documented the rise and expanded role of diagnostic imaging in the emergency department (ED). This article summarizes the discussions of the breakout session on the use of administrative data for emergency imaging research at the May 2015 Academic Emergency Medicine consensus conference, "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The authors describe the areas where administrative data have been applied to research evaluating the use of diagnostic imaging in the ED, the common sources for these data, and the strengths and limitations of administrative data. Next, the future role of administrative data is examined for answering key research questions in an evolving health system increasingly focused on measuring appropriateness, ensuring quality, and improving value for health spending. This article specifically focuses on four thematic areas: data quality, appropriateness and value, special populations, and policy interventions.

Emergency physician sex and emergency department resource use

OBJECTIVE

We investigated whether there are differences in emergency department (ED) patient management associated with emergency physician (EP) sex, specifically in terms of ordering investigations and hospital admissions.

METHODS

We included all EPs working as consultants for at least 24 consecutive months at a Spanish ED during an 8-year period. Every annual period was considered independently. The classificatory variable was EP sex. For every annual period we compiled age and years of experience of each EP, the number of patients who attended, and patient distribution in triage categories. To analyze ED resource use by each EP and period, we recorded percentages of blood tests, radiography, ultrasonography, computerized tomography (CT) scan, and hospital admission orders.

RESULTS

Fifty EPs (27 women and 23 men) were included, 291 annual periods were analyzed (132 for women and 159 for men) and 256 524 patient attendances were recorded (114 086 by women and 142 438 by men). Blood tests were ordered in 57.2% of cases, radiography in 58.0%, ultrasounds in 5.0%, CT scans in 7.0%, and hospitalizations in 28.4%. Compared with men, women ordered 6.8% (95% confidence interval 6.1-7.5%) more blood tests, 4.6% (4.3-5.3%) more radiographies, 15.2% (11.6-18.9%) more ultrasonographies, 11.1% (8.1-14.1%) more CT scans, and 12.1% (10.8-13.4%) more hospitalizations. These differences maintained statistical significance in the stratified analysis by EP experience, and were observed for most of the years analyzed.

CONCLUSION

Female EPs order more investigations and admit more patients, although from our results the reason for this is unclear, and the impact on healthcare effectiveness and patient outcome is unknown.

Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians

DESCRIPTION

Pulmonary embolism (PE) can be a severe disease and is difficult to diagnose, given its nonspecific signs and symptoms. Because of this, testing patients with suspected acute PE has increased dramatically. However, the overuse of some tests, particularly computed tomography (CT) and plasma d-dimer measurement, may not improve care while potentially leading to patient harm and unnecessary expense.

METHODS

The literature search encompassed studies indexed by MEDLINE (1966-2014; English-language only) and included all clinical trials and meta-analyses on diagnostic strategies, decision rules, laboratory tests, and imaging studies for the diagnosis of PE. This document is not based on a formal systematic review, but instead seeks to provide practical advice based on the best available evidence and recent guidelines. The target audience for this paper is all clinicians; the target patient population is all adults, both inpatient and outpatient, suspected of having acute PE.

BEST PRACTICE ADVICE 1

Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being considered.

BEST PRACTICE ADVICE 2

Clinicians should not obtain d-dimer measurements or imaging studies in patients with a low pretest probability of PE and who meet all Pulmonary Embolism Rule-Out Criteria.

BEST PRACTICE ADVICE 3

Clinicians should obtain a high-sensitivity d-dimer measurement as the initial diagnostic test in patients who have an intermediate pretest probability of PE or in patients with low pretest probability of PE who do not meet all Pulmonary Embolism Rule-Out Criteria. Clinicians should not use imaging studies as the initial test in patients who have a low or intermediate pretest probability of PE.

BEST PRACTICE ADVICE 4

Clinicians should use age-adjusted d-dimer thresholds (age × 10 ng/mL rather than a generic 500 ng/mL) in patients older than 50 years to determine whether imaging is warranted.

BEST PRACTICE ADVICE 5

Clinicians should not obtain any imaging studies in patients with a d-dimer level below the age-adjusted cutoff.

BEST PRACTICE ADVICE 6

Clinicians should obtain imaging with CT pulmonary angiography (CTPA) in patients with high pretest probability of PE. Clinicians should reserve ventilation-perfusion scans for patients who have a contraindication to CTPA or if CTPA is not available. Clinicians should not obtain a d-dimer measurement in patients with a high pretest probability of PE.

A Guide to Improving the Care of Patients with Fragility Fractures, Edition 2

Over the past 4 decades, much has been learned about the pathophysiology and treatment of osteoporosis, the prevention of fragility fractures, and the perioperative management of patients who have these debilitating injuries. However, the volume of published literature on this topic is staggering and far too voluminous for any clinician to review and synthesize by him or herself. This manuscript thoroughly summarizes the latest research on fragility fractures and provides the reader with valuable strategies to optimize the prevention and management of these devastating injuries. The information contained in this article will prove invaluable to any health care provider or health system administrator who is involved in the prevention and management of fragility hip fractures. As providers begin to gain a better understanding of the principles espoused in this article, it is our hope that they will be able to use this information to optimize the care they provide for elderly patients who are at risk of or who have osteoporotic fractures.

Emergency department practice variation in computed tomography use for children with minor blunt head trauma

OBJECTIVE

To describe factors associated with computed tomography (CT) use for children with minor blunt head trauma that are evaluated in emergency departments.

STUDY DESIGN

Planned secondary analysis of a prospective observational study of children <18 years with minor blunt head trauma between 2004 and 2006 at 25 emergency departments. CT scans were obtained at the discretion of treating clinicians. We risk-adjusted patients for clinically important traumatic brain injuries and performed multivariable regression analyses. Outcome measures were rates of CT use by hospital and by clinician training type.

RESULTS

CT rates varied between 19.2% and 69.2% across hospitals. Risk adjustment had little effect on the differential rate of CT use. In low- and middle-risk patients, clinicians obtained CTs more frequently at suburban and nonfreestanding children's hospitals. Physicians with emergency medicine (EM) residency training obtained CTs at greater rates than physicians with pediatric residency or pediatric EM training. In multivariable analyses, compared with pediatric EM-trained physicians, the OR for CT use among EM-trained physicians in children <2 years was 1.24 (95% CI 1.04-1.46), and for children >2 years was 1.68 (95% CI 1.50-1.89). Physicians of all training backgrounds, however, overused CT scans in low-risk children.

CONCLUSIONS

Substantial variation exists in the use of CT for children with minor blunt head trauma not explained by patient severity or rates of positive CT scans or clinically important traumatic brain injuries.