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Decker JH, Mazal AT, Bui A, Sprenger T, Skare S, Fischbein N, Zaharchuk G. NeuroMix with MRA: A Fast MR Protocol to Reduce Head and Neck CTA for Patients with Acute Neurologic Presentations. AJNR Am J Neuroradiol 2024:ajnr.A8386. [PMID: 38906674 DOI: 10.3174/ajnr.a8386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 06/11/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND AND PURPOSE Overuse of CT-based cerebrovascular imaging in the emergency department and inpatient settings, notably CTA of the head and neck for minor and nonfocal neurologic presentations, stresses imaging services and exposes patients to radiation and contrast. Furthermore, such CT-based imaging is often insufficient for definitive diagnosis, necessitating additional MR imaging. Recent advances in fast MRI may allow timely assessment and a reduced need for head and neck CTA in select populations. MATERIALS AND METHODS We identified inpatients or patients in the emergency department who underwent CTAHN (including noncontrast and postcontrast head CT, with or without CTP imaging) followed within 24 hours by a 3T MRI study that included a 2.5-minute unenhanced multicontrast sequence (NeuroMix) and a 5-minute intracranial time of flight MRA) during a 9-month period (April to December 2022). Cases were classified by 4 radiologists in consensus as to whether NeuroMix and NeuroMix + MRA detected equivalent findings, detected unique findings, or missed findings relative to CTAHN. RESULTS One hundred seventy-four cases (mean age, 67 [SD, 16] years; 56% female) met the inclusion criteria. NeuroMix alone and NeuroMix + MRA protocols were determined to be equivalent or better compared with CTAHN in 71% and 95% of patients, respectively. NeuroMix always provided equivalent or better assessment of the brain parenchyma, with unique findings on NeuroMix and NeuroMix + MRA in 35% and 36% of cases, respectively, most commonly acute infarction or multiple microhemorrhages. In 8/174 cases (5%), CTAHN identified vascular abnormalities not seen on the NeuroMix + MRA protocol due to the wider coverage of the cervical arteries by CTAHN. CONCLUSIONS A fast MR imaging protocol consisting of NeuroMix + MRA provided equivalent or better information compared with CTAHN in 95% of cases in our population of patients with an acute neurologic presentation. The findings provide a deeper understanding of the benefits and challenges of a fast unenhanced MR-first approach with NeuroMix + MRA, which could be used to design prospective trials in select patient groups, with the potential to reduce radiation dose, mitigate adverse contrast-related patient and environmental effects, and lessen the burden on radiologists and health care systems.
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Affiliation(s)
- Johannes H Decker
- From the Division of Neuroimaging and Neurointervention (J.H.D., A.T.M., A.B., N.F., G.Z.), Department of Radiology, Stanford University, Stanford, California
| | - Alexander T Mazal
- From the Division of Neuroimaging and Neurointervention (J.H.D., A.T.M., A.B., N.F., G.Z.), Department of Radiology, Stanford University, Stanford, California
| | - Amy Bui
- From the Division of Neuroimaging and Neurointervention (J.H.D., A.T.M., A.B., N.F., G.Z.), Department of Radiology, Stanford University, Stanford, California
| | - Tim Sprenger
- MR Applied Science Laboratory Europe (T.S.), GE Healthcare, Stockholm, Sweden
- Department of Clinical Neuroscience (T.S., S.S.), Karolinska Institutet, Stockholm, Sweden
| | - Stefan Skare
- Department of Clinical Neuroscience (T.S., S.S.), Karolinska Institutet, Stockholm, Sweden
| | - Nancy Fischbein
- From the Division of Neuroimaging and Neurointervention (J.H.D., A.T.M., A.B., N.F., G.Z.), Department of Radiology, Stanford University, Stanford, California
| | - Greg Zaharchuk
- From the Division of Neuroimaging and Neurointervention (J.H.D., A.T.M., A.B., N.F., G.Z.), Department of Radiology, Stanford University, Stanford, California
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D'Angelo T, Bucolo GM, Kamareddine T, Yel I, Koch V, Gruenewald LD, Martin S, Alizadeh LS, Mazziotti S, Blandino A, Vogl TJ, Booz C. Accuracy and time efficiency of a novel deep learning algorithm for Intracranial Hemorrhage detection in CT Scans. LA RADIOLOGIA MEDICA 2024:10.1007/s11547-024-01867-y. [PMID: 39123064 DOI: 10.1007/s11547-024-01867-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 08/01/2024] [Indexed: 08/12/2024]
Abstract
PURPOSE To evaluate a deep learning-based pipeline using a Dense-UNet architecture for the assessment of acute intracranial hemorrhage (ICH) on non-contrast computed tomography (NCCT) head scans after traumatic brain injury (TBI). MATERIALS AND METHODS This retrospective study was conducted using a prototype algorithm that evaluated 502 NCCT head scans with ICH in context of TBI. Four board-certified radiologists evaluated in consensus the CT scans to establish the standard of reference for hemorrhage presence and type of ICH. Consequently, all CT scans were independently analyzed by the algorithm and a board-certified radiologist to assess the presence and type of ICH. Additionally, the time to diagnosis was measured for both methods. RESULTS A total of 405/502 patients presented ICH classified in the following types: intraparenchymal (n = 172); intraventricular (n = 26); subarachnoid (n = 163); subdural (n = 178); and epidural (n = 15). The algorithm showed high diagnostic accuracy (91.24%) for the assessment of ICH with a sensitivity of 90.37% and specificity of 94.85%. To distinguish the different ICH types, the algorithm had a sensitivity of 93.47% and a specificity of 99.79%, with an accuracy of 98.54%. To detect midline shift, the algorithm had a sensitivity of 100%. In terms of processing time, the algorithm was significantly faster compared to the radiologist's time to first diagnosis (15.37 ± 1.85 vs 277 ± 14 s, p < 0.001). CONCLUSION A novel deep learning algorithm can provide high diagnostic accuracy for the identification and classification of ICH from unenhanced CT scans, combined with short processing times. This has the potential to assist and improve radiologists' ICH assessment in NCCT scans, especially in emergency scenarios, when time efficiency is needed.
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Affiliation(s)
- Tommaso D'Angelo
- Diagnostic and Interventional Radiology Unit, BIOMORF Department, University of Messina, Messina, Italy.
- Department of Radiology and Nuclear Medicine, Erasmus MC, 3015 GD, Rotterdam, The Netherlands.
| | - Giuseppe M Bucolo
- Diagnostic and Interventional Radiology Unit, BIOMORF Department, University of Messina, Messina, Italy
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Tarek Kamareddine
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Ibrahim Yel
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Vitali Koch
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Leon D Gruenewald
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Simon Martin
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Leona S Alizadeh
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Bundeswehr Central Hospital Koblenz, Koblenz, Germany
| | - Silvio Mazziotti
- Diagnostic and Interventional Radiology Unit, BIOMORF Department, University of Messina, Messina, Italy
| | - Alfredo Blandino
- Diagnostic and Interventional Radiology Unit, BIOMORF Department, University of Messina, Messina, Italy
| | - Thomas J Vogl
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Christian Booz
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
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3
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Ellenbogen MI, Weygandt PL, Newman-Toker DE, Anderson A, Rim N, Brotman DJ. Race and Ethnicity and Diagnostic Testing for Common Conditions in the Acute Care Setting. JAMA Netw Open 2024; 7:e2430306. [PMID: 39190305 DOI: 10.1001/jamanetworkopen.2024.30306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/28/2024] Open
Abstract
Importance Overuse of diagnostic testing is pervasive, but the extent to which it varies by race and ethnicity in the acute care setting is poorly understood. Objective To use a previously validated diagnostic intensity index to evaluate differences in diagnostic testing rates by race and ethnicity in the acute care setting, which may serve as a surrogate for diagnostic test overuse. Design, Setting, and Participants This was a cross-sectional study of emergency department (ED) discharges, hospital observation stays, and hospital admissions using administrative claims among EDs and acute care hospitals in Kentucky, Maryland, North Carolina, and New Jersey, from 2016 through 2018. The diagnostic intensity index pairs nonspecific principal discharge diagnoses (nausea and vomiting, abdominal pain, chest pain, and syncope) with related diagnostic tests to estimate rates of nondiagnostic testing. Adults with an acute care encounter with a principal discharge diagnosis of interest were included. Data were analyzed from January to February 2024. Exposure Race and ethnicity (Asian, Black, Hispanic, White, other [including American Indian, multiracial, and multiethnic], and missing). Main Outcomes and Measures Receipt of a diagnostic test. Generalized linear models with a hospital-specific indicator variable were estimated to calculate the adjusted odds ratio of receiving a test related to the principal discharge diagnosis by race and ethnicity, controlling for primary payer and zip code income quartile. Results Of 3 683 055 encounters (1 055 575 encounters [28.7%] for Black, 300 333 encounters [8.2%] for Hispanic, and 2 140 335 encounters [58.1%] for White patients; mean [SD] age of patients with encounters, 47.3 [18.8] years; 2 233 024 encounters among females [60.6%]), most (2 969 974 encounters [80.6%]) were ED discharges. Black compared with White patients discharged from the ED with a diagnosis of interest had an adjusted odds ratio of 0.74 (95% CI, 0.72-0.75) of having related diagnostic testing. No other racial or ethnic disparities of a similar magnitude were observed in any acute care settings. Conclusions and Relevance In this study, White patients discharged from the ED with a nonspecific diagnosis of interest were significantly more likely than Black patients to receive related diagnostic testing. The extent to which this represents diagnostic test overuse in White patients vs undertesting and missed diagnoses in Black patients deserves further study.
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Affiliation(s)
| | - P Logan Weygandt
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - David E Newman-Toker
- Armstrong Institute Center for Diagnostic Excellence, Johns Hopkins School of Medicine, Baltimore, Maryland
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Andrew Anderson
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Nayoung Rim
- Department of Economics, US Naval Academy, Annapolis, Maryland
| | - Daniel J Brotman
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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Luxenburg O, Vaknin S, Wilf-Miron R, Saban M. Evaluating the Accuracy and Impact of the ESR-iGuide Decision Support Tool in Optimizing CT Imaging Referral Appropriateness. JOURNAL OF IMAGING INFORMATICS IN MEDICINE 2024:10.1007/s10278-024-01197-5. [PMID: 39028357 DOI: 10.1007/s10278-024-01197-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 07/01/2024] [Accepted: 07/02/2024] [Indexed: 07/20/2024]
Abstract
Radiology referral quality impacts patient care, yet factors influencing quality are poorly understood. This study assessed the quality of computed tomography (CT) referrals, identified associated characteristics, and evaluated the ESR-iGuide clinical decision support tool's ability to optimize referrals. A retrospective review analyzed 300 consecutive CT referrals from an acute care hospital. Referral quality was evaluated on a 5-point scale by three expert reviewers (inter-rater reliability κ = 0.763-0.97). The ESR-iGuide tool provided appropriateness scores and estimated radiation exposure levels for the actual referred exams and recommended exams. Scores were compared between actual and recommended exams. Associations between ESR-iGuide scores and referral characteristics, including the specialty of the ordering physician (surgical vs. non-surgical), were explored. Of the referrals, 67.1% were rated as appropriate. The most common exams were head and abdomen/pelvis CTs. The ESR-iGuide deemed 70% of the actual referrals "usually appropriate" and found that the recommended exams had lower estimated radiation exposure compared to the actual exams. Logistic regression analysis showed that non-surgical physicians were more likely to order inappropriate exams compared to surgical physicians. Over one-third of the referrals showed suboptimal quality in the unstructured system. The ESR-iGuide clinical decision support tool identified opportunities to optimize appropriateness and reduce radiation exposure. Implementation of such a tool warrants consideration to improve communication and maximize patient care quality.
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Affiliation(s)
- Osnat Luxenburg
- Medical Technology, Health Information and Research Directorate, Ministry of Health, Jerusalem, Israel
| | - Sharona Vaknin
- The Gertner Institute for Health Policy and Epidemiology, Ramat-Gan, Israel
| | - Rachel Wilf-Miron
- Department of Health Promotion, School of Public Health, Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Mor Saban
- School of Health Professions, Faculty of Medical & Health Sciences, Tel-Aviv University, Tel-Aviv-Yafo, Israel.
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Mehan WA, Shin D, Buch K. Effect of Provider Type on Overutilization of CT Angiograms of the Head and Neck for Patients Presenting to the Emergency Department with Nonfocal Neurologic Symptoms. J Am Coll Radiol 2024; 21:890-895. [PMID: 37722466 DOI: 10.1016/j.jacr.2023.08.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/28/2023] [Accepted: 08/23/2023] [Indexed: 09/20/2023]
Abstract
PURPOSE Overutilization of neuroimaging in the emergency department (ED), especially CT angiogram of the head and neck (CTAHN) examinations, contributes to rising health care expenditures, exposes patients to radiation, and may result in delays in care. We evaluated the rate of CTAHN overutilization for patients with nonfocal neurologic complaints in the ED and its potential association with patient clinical data, demographic data, and ED provider type. METHODS This study was retrospective, was approved by an institutional review board, and was performed at a single institution, spanning a 6-year period. ED patients with nonfocal neurologic complaints who had a CTAHN examination with no history of trauma, recent surgery, or intracranial malignancy were included. Each CTAHN examination was categorized into one of four groups (0 = negative, 1 = chronic findings not related to presentation, 2 = nonacute and/or nonemergent findings or findings that may account for the presentation, and 3 = acute and/or emergent findings that may account for the presentation). Basic demographic data including patient age, patient sex, ordering ED provider type (attending, resident, nonphysician practitioner [(NPP]) were collected and analyzed using a multiple logistic regression analysis. RESULTS A total of 960 CTAHN examinations were reviewed. The mean age of patients was 50 years (SD = 18 years), with 63% female patients and 37% male patients. Headache was the most frequent presentation (76%). A total of 75% of cases were negative, and 7% had chronic imaging findings not related to their ED presentation. A total of 12.5% of cases had nonacute and/or nonemergent findings possibly related to the presentation, and only 5.5% had acute and/or emergent findings related to ED presentation. A significantly greater proportion of CTAHN examinations ordered by NPPs, followed by the proportion ordered by ED residents, were negative or had no findings related to the patient presentation, and these patients were ultimately discharged to home. DISCUSSION A total of 82% of ED CTAHN examinations performed for patients with nonfocal neurologic complaints had no actionable findings. These examinations are significantly more likely to be ordered by NPPs and ED residents.
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Affiliation(s)
- William A Mehan
- Associate Chair of Radiology Finance, Vice Chair of Finance, and Associate Chair of Off-Campus Imaging; Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and Member, ACR
| | - Donghoon Shin
- Neuroradiology Fellow, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and Member, ACR
| | - Karen Buch
- Neuroradiology Fellowship Program Director, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and Member, ACR.
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6
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Francisco MZ, Altmayer S, Carlesso L, Zanon M, Eymael T, Lima JE, Watte G, Hochhegger B. Appropriateness and imaging outcomes of ultrasound, CT, and MR in the emergency department: a retrospective analysis from an urban academic center. Emerg Radiol 2024; 31:367-372. [PMID: 38664279 DOI: 10.1007/s10140-024-02226-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/26/2024] [Indexed: 05/29/2024]
Abstract
PURPOSE To evaluate the appropriateness and outcomes of ultrasound (US), computed tomography (CT), and magnetic resonance (MR) orders in the ED. METHODS We retrospectively reviewed consecutive US, CT, and MR orders for adult ED patients at a tertiary care urban academic center from January to March 2019. The American College of Radiology Appropriateness Criteria (ACRAC) guidelines were primarily used to classify imaging orders as "appropriate" or "inappropriate". Two radiologists in consensus judged specific clinical scenarios that were unavailable in the ACRAC. Final imaging reports were compared with the initial clinical suspicion for imaging and categorized into "normal", "compatible with initial diagnosis", "alternative diagnosis", or "inconclusive". The sample was powered to show a prevalence of inappropriate orders of 30% with a margin of error of 5%. RESULTS The rate of inappropriate orders was 59.4% for US, 29.1% for CT, and 33.3% for MR. The most commonly imaged systems for each modality were neuro (130/330) and gastrointestinal (95/330) for CT, genitourinary (132/330) and gastrointestinal (121/330) for US, neuro (273/330) and gastrointestinal (37/330) for MR. Compared to inappropriately ordered tests, the final reports of appropriate orders were nearly three times more likely to demonstrate findings compatible with the initial diagnosis for all modalities: US (45.5 vs. 14.3%, p < 0.001), CT (46.6 vs. 14.6%, p < 0.001), and MR (56.3 vs. 21.8%, p < 0.001). Inappropriate orders were more likely to show no abnormalities compared to appropriate orders: US (65.8 vs. 38.8%, p < 0.001), CT (62.5 vs. 34.2%, p < 0.001), and MR (61.8 vs. 38.7%, p < 0.001). CONCLUSION The prevalence of inappropriate imaging orders in the ED was 59.4% for US, 29.1% for CT, and 33.3% for MR. Appropriately ordered imaging was three times more likely to yield findings compatible with the initial diagnosis across all modalities.
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Affiliation(s)
| | | | - Lucas Carlesso
- Universidade Federal de Ciencias da Saude de Porto Alegre, Porto Alegre, Brazil
| | - Matheus Zanon
- Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Thales Eymael
- Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Guilherme Watte
- Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil
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7
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Plasencia-Martínez JM, Sánchez-Canales M, Otón-González E, Casado-Alarcón NI, Molina-Lozano B, Cotillo-Ramos E, Ortiz-Mayoral H, García-Santos JM. Inappropriate requests for cranial CT scans in emergency departments increase overuse and reduce test performance. Emerg Radiol 2023; 30:733-741. [PMID: 37973624 DOI: 10.1007/s10140-023-02185-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/01/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE The number of non-traumatic urgent cranial computed tomography (NT-UCCT) is exponentially increasing but limited research has been conducted on the quality of clinical justification. Accordingly, we aimed (1) to assess how clinical information in the electronic NT-UCCT request agreed with that provided in the patient's emergency department discharge summary and (2) to analyze the potential effect of those discrepancies on the NT-UCCT overload. MATERIAL AND METHODS Patients undergoing NT-UCCT in 2017-2021 were randomly selected for this retrospective research-board-approved study. Signs and symptoms (S/S) in electronic request and emergency department discharge summary, acute and relevant computed tomography (CT) findings (acute ischemia or hemorrhage, masses, brain edema, or previously undetected hydrocephalus), and final diagnosis at emergency department discharge summary were collected. Concordance between digital request and emergency department discharge summary and their association with both acute and relevant CT findings and final diagnosis were analyzed. RESULTS We recruited 156 patients: 80 men; mean age, 55. Acute, relevant CT findings were detected in 28 cases (17.9%). The final diagnosis was neurological disease, non-neurological disease, and no definitive diagnosis in 46 (29.5%), 58 (37.2%), and 51 (32.7%) cases, respectively. Full agreement between the electronic request and emergency department discharge summary occurred in only 36 patients (23.1%). Motor deficit was the most frequent false positive electronic request S/S (18; 11.54%), having low positive predictive value (30.30%; 95%CI 15.59-48.71%) and worst association with acute relevant CT findings than when true positive (OR 2.54; 95%CI 0.04-6.21 vs. OR 6.26, 95%CI 2.21-17.78). Nausea/vomiting was the third most common false negative electronic request S/S (13; 10.26%) and reduced the likelihood of acute and relevant CT findings (OR 0.126; 95%CI 0.016-0.971; p = 0.020). False S/S in electronic request predominated in non-neurological diseases (50-60.2% vs. 33-39.8%; p = 0.068). CONCLUSION Discrepancies between electronic request and emergency department discharge summary were observed in >75% of patients, leading to unnecessary NT-UCCT tests.
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Affiliation(s)
- Juana María Plasencia-Martínez
- Department of Radiology, Hospital General Universitario Morales Meseguer, Avenida Marqués de los Vélez, s/n, 30008, Murcia, Spain.
| | - Marta Sánchez-Canales
- Department of Radiology, Hospital General Universitario Morales Meseguer, Avenida Marqués de los Vélez, s/n, 30008, Murcia, Spain
| | - Elena Otón-González
- Department of Radiology, Hospital General Universitario Morales Meseguer, Avenida Marqués de los Vélez, s/n, 30008, Murcia, Spain
| | - Nuria Isabel Casado-Alarcón
- Department of Radiology, Hospital General Universitario Morales Meseguer, Avenida Marqués de los Vélez, s/n, 30008, Murcia, Spain
| | | | - Estefanía Cotillo-Ramos
- Department of Radiology, Hospital General Universitario Morales Meseguer, Avenida Marqués de los Vélez, s/n, 30008, Murcia, Spain
| | - Herminia Ortiz-Mayoral
- Department of Radiology, Hospital General Universitario Morales Meseguer, Avenida Marqués de los Vélez, s/n, 30008, Murcia, Spain
| | - José María García-Santos
- Department of Radiology, Hospital General Universitario Morales Meseguer, Avenida Marqués de los Vélez, s/n, 30008, Murcia, Spain
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8
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Alattar Z, Keric N. Evaluation of Abdominal Emergencies. Surg Clin North Am 2023; 103:1043-1059. [PMID: 37838455 DOI: 10.1016/j.suc.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Early primary assessment and abdominal examination can often be enough to triage the patient with abdominal pain into those with less severe underlying pathologic condition from those with more acute findings. A focused history of the patient can then allow the clinician to develop their differential diagnosis. Once the differential diagnoses are determined, diagnostic imaging and laboratory findings can help confirm the diagnosis and allow for expeditious treatment and intervention.
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Affiliation(s)
- Zana Alattar
- University of Arizona College of Medicine-Phoenix, 1441 North 12th Street, First Floor, Phoenix, AZ 85006, USA
| | - Natasha Keric
- University of Arizona College of Medicine-Phoenix, Banner-University Medical Center Phoenix, 1441 North 12th Street, First Floor, Phoenix, AZ 85006, USA.
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9
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Helms R. Improving the Management of Adults With Mild Traumatic Brain Injury: An Initiative to Reduce Unnecessary Computed Tomographic Scans in the Emergency Department. Adv Emerg Nurs J 2023; 45:327-340. [PMID: 37885087 DOI: 10.1097/tme.0000000000000489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
The overuse of computed tomographic (CT) scans for patients who present to the emergency department (ED) after mild traumatic brain injury (mTBI) has been well-documented. The Canadian Computed Tomography Head Rule (CCHR) is a validated tool to guide ED providers in determining the need for emergent CT of mTBI patients. The purpose of this project was to reduce radiation exposure and ED length of stay by using the CCHR to decrease unnecessary CT scans in adults with TBI. Cost of care was also estimated. The CCHR implementation strategy included an education program for ED staff. The use of the CCHR was promoted throughout the intervention period. The outcomes measured were the number of CT scans ordered, ED length of stay, and the cost of avoidable CT scans. Data were collected through medical record reviews completed by the project leader and were evaluated using the independent samples t test. A total of 600 medical records were reviewed. There was a significant difference between adherence to the CCHR before (M = 64.6%) and after provider education (M = 74.3%). The percentage of CT scans that could have been avoided significantly decreased from baseline (M = 0.63) after provider education (M = 0.46). Length of stay for mTBI patients who were managed based on the CCHR (M = 184.9) was significantly less than the length of stay for those who were not (M = 260.1). The cost of avoidable scans was decreased by 37% over the course of the project. There were no incidents of missed diagnosis found. By increasing awareness of the CCHR and promoting its use, the number of head CT scans ordered, cost of care, and ED length of stay for patients who present after mTBI were significantly improved.
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Affiliation(s)
- Rachel Helms
- College of Nursing, Auburn University, Auburn, Alabama
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Al-Arimi AH, Hazra D, Al-Alawi AKA. Impact of Fatigue on Emergency Physicians' Decision-making for Computed Tomographic Scan Requests and Inpatient Referrals: An Observational Study from a Tertiary Care Medical Center of the Sultanate of Oman. Indian J Crit Care Med 2023; 27:620-624. [PMID: 37719345 PMCID: PMC10504659 DOI: 10.5005/jp-journals-10071-24520] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/28/2023] [Indexed: 09/19/2023] Open
Abstract
Objective Multiple factors contribute to decision fatigue experienced by emergency physicians (EPs). This study examines the association between decision fatigue and the frequency of computed tomographic (CT) scan requests and inpatient referrals among EPs. Methods This retrospective database analysis was done for 3 months. Scans and inpatient referral requests were coded and analyzed to assess the impact of physician fatigue on decision-making. Subsequently, the outcomes were evaluated. Results The majority of patients (n = 481; 51.1%) had a CT brain request. Among these requests, the morning shift (8:00 a.m.-3:00 p.m.) accounted for the highest number (n = 400; 42.5%), followed by the evening shift (3:00-11:00 p.m.) (n = 345; 36.7%). Approximately one-third of the patients (n = 301; 31.9%) had positive CT scan findings. Statistical analysis comparing the first and the second halves of each shift did not reveal significant variations in the percentage of negative CT results (p-value: 0.093). Inpatient referral was necessary for over half of the patients (n = 1,048; 52.7%), and the majority of these referrals (n = 778; 74.2%) were deemed necessary for treatment under various surgical or medical specialties. There was a statistically significant difference in the proportion of negative inpatient referrals between the first and the second halves of the afternoon shift (p-value < 0.001). Conclusions Fatigue among EPs was observed, leading to more frequent consultations without inpatient admission during the latter half of the afternoon shift. However, the study found no significant impact of decision fatigue on CT scan decision-making. How to cite this article Al-Arimi AH, Hazra D, Al-Alawi AKA. Impact of Fatigue on Emergency Physicians' Decision-making for Computed Tomographic Scan Requests and Inpatient Referrals: An Observational Study from a Tertiary Care Medical Center of the Sultanate of Oman. Indian J Crit Care Med 2023;27(9):620-624.
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Affiliation(s)
- Asma H Al-Arimi
- Emergency Medicine Residency Training Program, Oman Medical Specialty Board, Muscat, Sultanate of Oman
| | - Darpanarayan Hazra
- Department of Emergency Medicine, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
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Markus T, Saban M, Sosna J, Assaf J, Cohen D, Vaknin S, Luxenburg O, Singer C, Shaham D. Does clinical decision support system promote expert consensus for appropriate imaging referrals? Chest-abdominal-pelvis CT as a case study. Insights Imaging 2023; 14:45. [PMID: 36929357 PMCID: PMC10020384 DOI: 10.1186/s13244-023-01371-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 01/03/2023] [Indexed: 03/18/2023] Open
Abstract
OBJECTIVES We assessed the appropriateness of chest-abdominal-pelvis (CAP) CT scan use in the Emergency Department (ED), based on expert physicians and the ESR iGuide, a clinical decision support system (CDSS). METHODS A retrospective cross-study was conducted. We included 100 cases of CAP-CT scans ordered at the ED. Four experts rated the appropriateness of the cases on a 7-point scale, before and after using the decision support tool. RESULTS Before using the ESR iGuide the overall mean rating of the experts was 5.2 ± 1.066, and it increased slightly after using the system (5.85 ± 0.911 (p < 0.01)). Using a threshold of 5 (on a 7-level scale), the experts considered only 63% of the tests appropriate before using the ESR iGuide. The number increased to 89% after consultation with the system. The degree of overall agreement among the experts was 0.388 before ESR iGuide consultation and 0.572 after consultation. According to the ESR iGuide, for 85% of the cases, CAP CT was not a recommended option (score 0). Abdominal-Pelvis CT was "usually appropriate" for 65 out of the 85 (76%) cases (score 7-9). 9% of the cases did not require CT as first exam modality. CONCLUSIONS According to both the experts and the ESR iGuide, inappropriate testing was prevalent, in terms of both frequency of the scans and also inappropriately chosen body regions. These findings raise the need for unified workflows that might be achieved using a CDSS. Further studies are needed to investigate the CDSS contribution to the informed decision-making and increased uniformity among different expert physicians when ordering the appropriate test.
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Affiliation(s)
- Talya Markus
- Department of Radiology, Hadassah Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - Mor Saban
- The Gertner Institute for Epidemiology and Health Policy Research, Sheba medical center, Ramat Gan, Israel.,Nursing Department, School of Health Professions, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv-Yafo, Israel
| | - Jacob Sosna
- Department of Radiology, Hadassah Hebrew University Medical Center, 91120, Jerusalem, Israel.
| | - Jacob Assaf
- Emergency Department, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Dotan Cohen
- Department of Radiology, Hadassah Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - Sharona Vaknin
- The Gertner Institute for Epidemiology and Health Policy Research, Sheba medical center, Ramat Gan, Israel
| | - Osnat Luxenburg
- Medical Technology, Health Information and Research Directorate, Ministry of Health, Jerusalem, Israel
| | - Clara Singer
- The Gertner Institute for Epidemiology and Health Policy Research, Sheba medical center, Ramat Gan, Israel
| | - Dorith Shaham
- Department of Radiology, Hadassah Hebrew University Medical Center, 91120, Jerusalem, Israel
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Pourvaziri A, Mojtahed A, Hahn PF, Gee MS, Kambadakone A, Sahani DV. Renal lesion characterization: clinical utility of single-phase dual-energy CT compared to MRI and dual-phase single-energy CT. Eur Radiol 2023; 33:1318-1328. [PMID: 36074261 DOI: 10.1007/s00330-022-09106-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 07/13/2022] [Accepted: 08/10/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To assess the impact of dual-energy CT (DECT) utilization in practice by measuring the readers' confidence, the need for additional image requests, and diagnostic performance in renal lesion assessment, compared to single-energy CT (SECT) using contrast-enhanced MRI to establish the reference standard. MATERIALS AND METHODS Sixty-nine patients (M/F = 47/22) who underwent a dual-phase renal SECT (n = 34) or DECT (n = 35) and had a contrast-enhanced MRI within 180 days were retrospectively collected. Three radiologists assessed images on different sessions (SECT, DECT, and MRI) for (1) likely diagnosis (enhancing/non-enhancing); (2) diagnostic confidence (5-point Likert scale); (3) need for additional imaging test (yes/no); and (4) need for follow-up imaging (yes/no). Diagnostic accuracy was compared using AUC; p value < 0.05 was considered significant. RESULTS One hundred fifty-six lesions consisting of 18% enhancing (n = 28/156, mean size: 30.37 mm, range: 9.9-94 mm) and 82% non-enhancing (n = 128/156, mean size: 23.91 mm, range: 5.0-94.2 mm) were included. The confidence level was significantly lower for SECT than their MRI (4.50 vs. 4.80, p value < 0.05) but not significantly different for DECT and the corresponding MRI (4.78 vs. 4.78, p > 0.05). There were significantly more requests for additional imaging in the SECT session than the corresponding MRI (20% vs. 4%), which was not significantly different between DECT and their MRI counterpart session (5.7% vs. 4.9%). Inter-reader agreement was almost perfect for DECT and MRI (kappa: 0.8-1) and substantial in SECT sessions (kappa: 0.6-0.8) with comparable diagnostic accuracy between SECT, DECT, and MRI (p value > 0.05). CONCLUSION Single-phase DECT allows confident and reproducible characterization of renal masses with fewer recommendation for additional and follow-up imaging tests than dual-phase SECT and a performance similar to MRI. KEY POINTS • DECT utilization leads to similar additional image requests to MRI (5.7% vs. 4.9%, p value > 0.05), whereas single-energy CT utilization leads to significantly higher image requests (20% vs. 4%, p value < 0.05). • DECT and MRI utilization bring highly reproducible results with almost perfect inter-reader agreement (kappa: 0.8-1), better than the inter-reader agreement in SECT utilization (kappa: 0.6-0.8). • Readers' confidence was not significantly altered between DECT and their MRI readout session (p value > 0.05). In contrast, confidence in the diagnosis was significantly lower in the SECT session than their MRI readout (p value < 0.05).
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Affiliation(s)
- Ali Pourvaziri
- Department of Radiology, Massachusetts General Hospital, 55 Fruit St, White 270, Boston, MA, 02114, USA.
| | - Amirkasra Mojtahed
- Department of Radiology, Massachusetts General Hospital, 55 Fruit St, White 270, Boston, MA, 02114, USA
| | - Peter F Hahn
- Department of Radiology, Massachusetts General Hospital, 55 Fruit St, White 270, Boston, MA, 02114, USA
| | - Michael S Gee
- Department of Radiology, Massachusetts General Hospital, 55 Fruit St, White 270, Boston, MA, 02114, USA
| | - Avinash Kambadakone
- Department of Radiology, Massachusetts General Hospital, 55 Fruit St, White 270, Boston, MA, 02114, USA
| | - Dushyant V Sahani
- Department of Radiology, University of Washington, Seattle, WA, 98195, USA
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Linet MS, Applegate KE, McCollough CH, Bailey JE, Bright C, Bushberg JT, Chanock SJ, Coleman J, Dalal NH, Dauer LT, Davis PB, Eagar RY, Frija G, Held KD, Kachnic LA, Kiess AP, Klein LW, Kosti O, Miller CW, Miller-Thomas MM, Straus C, Vapiwala N, Wieder JS, Yoo DC, Brink JA, Dalrymple JL. A Multimedia Strategy to Integrate Introductory Broad-Based Radiation Science Education in US Medical Schools. J Am Coll Radiol 2023; 20:251-264. [PMID: 36130692 PMCID: PMC10578400 DOI: 10.1016/j.jacr.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 12/27/2022]
Abstract
US physicians in multiple specialties who order or conduct radiological procedures lack formal radiation science education and thus sometimes order procedures of limited benefit or fail to order what is necessary. To this end, a multidisciplinary expert group proposed an introductory broad-based radiation science educational program for US medical schools. Suggested preclinical elements of the curriculum include foundational education on ionizing and nonionizing radiation (eg, definitions, dose metrics, and risk measures) and short- and long-term radiation-related health effects as well as introduction to radiology, radiation therapy, and radiation protection concepts. Recommended clinical elements of the curriculum would impart knowledge and practical experience in radiology, fluoroscopically guided procedures, nuclear medicine, radiation oncology, and identification of patient subgroups requiring special considerations when selecting specific ionizing or nonionizing diagnostic or therapeutic radiation procedures. Critical components of the clinical program would also include educational material and direct experience with patient-centered communication on benefits of, risks of, and shared decision making about ionizing and nonionizing radiation procedures and on health effects and safety requirements for environmental and occupational exposure to ionizing and nonionizing radiation. Overarching is the introduction to evidence-based guidelines for procedures that maximize clinical benefit while limiting unnecessary risk. The content would be further developed, directed, and integrated within the curriculum by local faculties and would address multiple standard elements of the Liaison Committee on Medical Education and Core Entrustable Professional Activities for Entering Residency of the Association of American Medical Colleges.
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Affiliation(s)
- Martha S Linet
- Chief and Senior Investigator, Radiation Epidemiology Branch (retired) and currently NIH Scientist Emerita, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
| | - Kimberly E Applegate
- Division Chief and Professor of Pediatric Radiology (retired), University of Kentucky Children's Hospital, University of Kentucky, Lexington, Kentucky, and currently Chair of Committee 3 of the International Commission on Radiological Protection, Ottawa, Canada
| | - Cynthia H McCollough
- Brooks-Hollern Professor of Medical Physics and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
| | - Janet E Bailey
- Professor of Radiology and Associate Chair for Education in Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Cedric Bright
- Associate Dean for Admissions and Clinical Professor, Department of Internal Medicine, East Carolina's Brody School of Medicine, Greenville, North Carolina
| | - Jerrold T Bushberg
- Clinical Professor of Radiology and Radiation Oncology, University of California Davis School of Medicine, Sacramento, California, and Vice President, National Council of Radiation Protection and Measurements, Bethesda, Maryland
| | - Stephen J Chanock
- Director and Chief of the Cancer Genomics Research Laboratory, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jenna Coleman
- Executive Director of the Medical Educational Council of Pensacola, Pensacola, Florida
| | - Nicole H Dalal
- Resident, Department of Internal Medicine, University of California San Francisco School of Medicine, San Francisco, California
| | - Lawrence T Dauer
- Attending Physicist, Departments of Medical Physics and Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Pamela B Davis
- Dean School of Medicine (emerita) and Arline H. and Curtis F. Garvin Research Professor, Center for Community Health Integration, and Professor of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Robert Y Eagar
- Diagnostic Radiology Resident, Department of Radiology, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Guy Frija
- Professor of Radiology (Emeritus), Université de Paris, Paris, France
| | - Kathryn D Held
- President of the National Council on Radiation Protection and Measurements, Bethesda, Maryland, and Associate Radiation Biologist, Department of Radiation Oncology, Massachusetts General Hospital and Associate Professor of Radiation Oncology, Harvard Medical School, Boston, Massachusetts
| | - Lisa A Kachnic
- Chair, Department of Radiation Oncology, Columbia University Medical Center and the Herbert Irving Comprehensive Cancer Center, New York, New York
| | - Ana P Kiess
- Assistant Professor of Radiation Oncology and Molecular Radiation Sciences and Director of the Residency Program, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Lloyd W Klein
- Clinical Professor of Medicine, University of California San Francisco School of Medicine, San Francisco, California
| | - Ourania Kosti
- Senior Program Officer at the Nuclear and Radiation Studies Board of the National Academies of Sciences, Engineering, and Medicine, Washington, DC
| | - Charles W Miller
- Chief (retired) Radiation Studies Branch, Division of Environmental Hazards and Health Effects, Centers for Disease Control and Prevention, Atlanta, Georgia, and currently a Consultant in Nuclear and Radiological Environmental Health, Atlanta, Georgia
| | - Michelle M Miller-Thomas
- Associate Professor of Radiology and Director of Medical Student Education at Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri
| | - Christopher Straus
- Associate Professor of Radiology and Director of Medical Student Education, University of Chicago School of Medicine, Chicago, Illinois
| | - Neha Vapiwala
- Professor and Vice Chair of Education, Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jessica S Wieder
- Director of the Center for Radiation Information and Outreach, US Environmental Protection Agency, Washington, DC
| | - Don C Yoo
- Director of Nuclear Medicine, Miriam Hospital and Professor of Diagnostic Imaging and Clinical Educator, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - James A Brink
- Chair, Department of Radiology, Brigham and Women's Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John L Dalrymple
- Professor of Obstetrics, Gynecology and Reproductive Biology and Associate Dean for Medical Education Quality Improvement, Harvard Medical School, Boston, Massachusetts, and Associate Chair and Vice Chair for Faculty Development and Faculty Affairs and Gynecologic Oncology Fellowship Program Director, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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14
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Lin LC, Gupta R, McIntyre BB, Castillo EW, Kreshak AA, Vilke GM. Frequency and Outcomes of Cervical Spine Computed Tomography Imaging on Alcohol-Intoxicated Patients in the Emergency Department. J Emerg Med 2023; 64:121-128. [PMID: 36781341 DOI: 10.1016/j.jemermed.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 10/08/2022] [Accepted: 11/06/2022] [Indexed: 02/13/2023]
Abstract
BACKGROUND Cervical spinal (c-spine) injuries range greatly in severity from minor ligamentous injuries to osteoligamentous instability with spinal cord injuries. Initial evaluation begins with stabilization as needed and immediate immobilization. Current practice as to whether the c-spine can be cleared clinically without radiographic evaluation is often guided by using the National Emergency X-Radiography Utilization Study Low-Risk Criteria and the Canadian C-Spine Rule. Under these clinical decision guidelines, stable trauma patients presenting with alcohol intoxication cannot have the c-spine cleared clinically and imaging should be "considered." OBJECTIVE This study aimed to assess the frequency of computed tomography (CT) c-spine scans ordered for patients presenting with alcohol intoxication to the emergency department (ED), the timing of the studies, and subsequently determine the proportion of which showed a clinically significant result that required intervention. METHODS In this retrospective medical record review, all clinically alcohol-intoxicated patients presenting to two academic EDs were included. Overall demographic characteristics, time to order of CT imaging, radiology reads, and outcomes of patient visits were determined. RESULTS There were 8008 patient visits included in the study. Of these visits, 5 patients scanned in ≤3 h had acute findings on CT scan and no patients with a deferred timing of CT scan after patients metabolized had an acute finding on CT scan. No patients required operative management. CONCLUSIONS This study's results suggest that it is a safe clinical practice to defer CT imaging for patients presenting to the ED with alcohol intoxication and low suspicion for c-spine injury per history and examination.
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Affiliation(s)
- Lucia C Lin
- University of California San Diego School of Medicine, San Diego, California
| | - Rishi Gupta
- Kansas City University College of Osteopathic Medicine, Kansas City, Missouri
| | - Brendan B McIntyre
- University of California San Diego School of Medicine, San Diego, California
| | - Edward W Castillo
- Department of Emergency Medicine, University of California San Diego, San Diego, California
| | - Allyson A Kreshak
- Department of Emergency Medicine, University of California San Diego, San Diego, California
| | - Gary M Vilke
- Department of Emergency Medicine, University of California San Diego, San Diego, California
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15
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Freire GC, Diong C, Gandhi S, Saunders N, Neuman MI, Freedman SB, Friedman JN, Cohen E. Variation in low-value radiograph use for children in the emergency department: a cross-sectional study of administrative databases. CMAJ Open 2022; 10:E889-E899. [PMID: 36220182 PMCID: PMC9578750 DOI: 10.9778/cmajo.20210140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Radiograph use contributes to low-value care for children in emergency departments (EDs), but little is known about systemic factors associated with their use. This study compares low-value radiograph use across ED settings by hospital type, pediatric volumes and physician specialty. METHODS This is a cross-sectional study of routinely collected administrative data. We included children (age 0-18 yr) discharged from EDs in Ontario, Canada, between 2010 and 2019 with diagnoses of bronchiolitis, asthma, abdominal pain and constipation. Multiple clinical practice guidelines recommend against routine radiograph use in these conditions. Logistic regression evaluated odds of low-value radiograph by ED setting (pediatric academic [referent], adult academic, community with or without pediatric consultation services), pediatric volume and physician specialty (pediatric emergency medicine [PEM, referent], emergency medicine [EM], family medicine with EM training, pediatrics, family medicine), adjusting for demographic, clinical and provider characteristics. We used generalized estimating equations to account for clustering by ED. RESULTS Of the total 9 862 787 eligible pediatric ED discharges in Ontario, 60 914 children had bronchiolitis, 141 921 asthma, 333 332 abdominal pain and 110 514 constipation; 26.0% received low-value radiographs. Compared with pediatric EDs and PEM physicians (referents), patients with bronchiolitis were most likely to have a chest radiograph in adult academic EDs (adjusted odds ratio [OR] 5.1 [95% confidence interval (CI) 4.6-5.6]) and by family physicians with EM training (adjusted OR 4.8 [95% CI 4.5-5.1]). Patients with asthma were more likely to have a chest radiograph in adult academic EDs (adjusted OR 3.0 [95% CI 2.8-3.2]) and by EM physicians (adjusted OR 2.8 [95% CI 2.6-3.0]). Patients with abdominal pain and constipation were more likely to have abdominal radiographs in community hospitals with pediatric consultation (adjusted OR 1.6 [95% CI 1.6-1.7] and 2.3 [95% CI 2.3-2.4], respectively) and by family physicians with EM training (adjusted OR 1.6 [95% CI 1.6-1.7] and 2.1 [95% CI 2.0-2.2], respectively). INTERPRETATION Over the decade-long study period, low-value radiograph use was frequent for children with 4 common conditions seen in Ontario EDs. Quality improvement initiatives aimed at reducing unnecessary radiographs in children should focus on EM physicians practising in EDs that primarily treat adult patients.
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Affiliation(s)
- Gabrielle C Freire
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Christina Diong
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Sima Gandhi
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Natasha Saunders
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Mark I Neuman
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Stephen B Freedman
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Jeremy N Friedman
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Eyal Cohen
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta.
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Abiala G, Bérubé M, Mercier É, Yanchar N, Stelfox HT, Archambault P, Bourgeois G, Belcaid A, Neveu X, Isaac CJ, Clément J, Lamontagne F, Moore L. Pre- and posttransfer computed tomography imaging in Canadian trauma centers: A multicenter retrospective cohort study. Acad Emerg Med 2022; 29:1084-1095. [PMID: 35612384 DOI: 10.1111/acem.14536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 05/03/2022] [Accepted: 05/21/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Multiple clinical practice guidelines recommend minimizing radiation in trauma patients but there is a knowledge gap on the importance of this problem for trauma transfers. We aimed to estimate the incidence of pretransfer and repeat posttransfer computed tomography (CT) overall and in patients with an indication for immediate transfer, to assess interhospital practice variation, to identify predictors, and to quantify the influence of pretransfer CT on time to transfer. Methods We conducted a retrospective multicenter cohort study on patients transferred to major trauma centers from 2013 to 2019. Multilevel generalized linear regression was used to generate intraclass correlation coefficients (ICCs) to assess interhospital variation, multilevel logistic regression to generate odds ratios for each predictor, and geometric mean ratios to quantify the influence of CT on time to transfer. Results Of 18,244 patients included, 8501 (47%) had a pretransfer CT and one-quarter (26%) had a repeat posttransfer CT. Interhospital variation was moderate for pretransfer CT (5%-66%, ICC 12.5%) and for repeat posttransfer CT (7%-44%, ICC 14.7%). Pretransfer imaging was more frequent in elders and in males and repeat posttransfer imaging decreased over the study period but was more frequent in patients transferred in from Level III/IV centers than nondesignated hospitals. Time to transfer was doubled in patients who had a pretransfer CT. CONCLUSIONS Results suggest that pretransfer CT and repeat posttransfer CT are frequent and are subject to significant practice variation. In addition, pretransfer CT is associated with increased times to transfer though additional studies are needed to demonstrate causation. These results highlight potential opportunities to reduce low-value imaging for trauma transfers.
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Affiliation(s)
- Godwill Abiala
- Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine, Centre de Recherche du CHU de Québec, Laval University (Hôpital de l'Enfant-Jésus), Laval University, Québec, Québec, Canada.,Department of Social and Preventive Medicine, Laval University, Québec, Québec, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine, Centre de Recherche du CHU de Québec, Laval University (Hôpital de l'Enfant-Jésus), Laval University, Québec, Québec, Canada
| | - Éric Mercier
- Department of Family Medicine and Emergency Medicine, Laval University, Québec City, Québec, Canada
| | - Natalie Yanchar
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - H Thomas Stelfox
- Department of Critical Care Medicine, Medicine and Community Health Sciences (HTS), Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Patrick Archambault
- Department of Family Medicine and Emergency Medicine, Laval University, Québec City, Québec, Canada.,Centre de recherche intégré pour un système apprenant en santé et en services sociaux Lévis, Lévis, Québec, Canada.,VITAM-Centre de recherche en santé durable, Québec City, Québec, Canada
| | - Gilles Bourgeois
- Institut National d'Excellence en Santé et en Services Sociaux, Québec City, Québec, Canada
| | - Amina Belcaid
- Institut National d'Excellence en Santé et en Services Sociaux, Québec City, Québec, Canada
| | - Xavier Neveu
- Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine, Centre de Recherche du CHU de Québec, Laval University (Hôpital de l'Enfant-Jésus), Laval University, Québec, Québec, Canada
| | - Chartelin J Isaac
- Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine, Centre de Recherche du CHU de Québec, Laval University (Hôpital de l'Enfant-Jésus), Laval University, Québec, Québec, Canada.,Department of Social and Preventive Medicine, Laval University, Québec, Québec, Canada
| | - Julien Clément
- Department of Surgery, University Laval, Québec City, Québec, Canada
| | - François Lamontagne
- Department of Medicine, Centre de recherche du CHU de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Lynne Moore
- Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine, Centre de Recherche du CHU de Québec, Laval University (Hôpital de l'Enfant-Jésus), Laval University, Québec, Québec, Canada.,Department of Social and Preventive Medicine, Laval University, Québec, Québec, Canada
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17
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How are Patient Order and Shift Timing Associated With Imaging Choices in the Emergency Department? Evidence From Niagara Health Administrative Data. Ann Emerg Med 2022; 80:392-400. [PMID: 35953385 DOI: 10.1016/j.annemergmed.2022.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 06/03/2022] [Accepted: 06/03/2022] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE We assessed whether the timing and order of patients over emergency shifts are associated with receiving diagnostic imaging in the emergency department and characterized whether changes in imaging are associated with changes in patients returning to the ED. METHODS In this retrospective study, we used multivariate and instrumental variable regressions to examine how the timing and order of patients are associated with the use of diagnostic imaging. Outcomes include whether a patient receives a radiograph, a computed tomography (CT) scan, an ultrasound, and 7-day bouncebacks to the ED. The variables of interest are time and order during a physician's shift in which a patient is seen. RESULTS A total of 841,683 ED visits were examined from an administrative database of all ED visits to Niagara Health. Relative to the first patient, the probability of receiving a radiograph, CT, and ultrasound decreases by 6.4%, 9.1%, and 3.8% if a patient is the 15th patient seen during a shift. Relative to the first minute, the probability of receiving a radiograph, CT, or ultrasound increases by 1.9%, 2.7%, and 1.1% if a patient is seen in the 180th minute. Seven-day bounceback rates are not consistently associated with patient order or timing in a shift and imaging orders. CONCLUSION Imaging in the ED is associated with shift length and especially patient order, suggesting that physicians make different imaging decisions over the course of their shifts. Additional imaging does not translate into reductions in subsequent bouncebacks to the hospital.
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18
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Dunne CL, Elzinga JL, Vorobeichik A, Sudershan S, Keto-Lambert D, Lang E, Dowling S. A Systematic Review of Interventions to Reduce Computed Tomography Usage in the Emergency Department. Ann Emerg Med 2022; 80:548-560. [PMID: 35927114 DOI: 10.1016/j.annemergmed.2022.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/26/2022] [Accepted: 06/02/2022] [Indexed: 12/19/2022]
Abstract
STUDY OBJECTIVE Unnecessary computed tomography (CT) scans burden the health care system, leading to increased emergency department (ED) wait times and lengths of stay, costing almost a billion dollars annually. This study aimed to describe ED-based interventions that are most effective at reducing CT imaging while maintaining diagnostic accuracy and patient safety. METHODS Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and Google Scholar were searched until December 31, 2020. Randomized and nonrandomized studies that assessed the effect of an ED-based intervention on CT scan usage were included. Abstract screening, data extraction, and quality assessment were conducted in duplicate. The Grading of Recommendation Assessment, Development and Evaluation framework, with the Risk of Bias 2 and Risk of Bias in Nonrandomized Studies - of Interventions tools, was used to determine the certainty of evidence. Significant clinical and statistical heterogeneity precluded meta-analysis; hence, a narrative synthesis was conducted. RESULTS A total of 149 studies were included of 5,667 screened abstracts, with substantial interrater reliability among reviewers (Cohen's κ>0.60). The CT reduction strategies were categorized into 15 single and 11 multimodal interventions by consensus review. Interventions that consistently reduced CT usage included diagnostic pathways, alternative test availability, specialist involvement, and provider feedback. Family/patient education, clinical decision support tools, or passive guideline dissemination did not consistently reduce usage. Only 44% of studies reported unintended consequences of reduction strategies; however, these showed no increase in missed diagnoses or patient harm. The interventions that engaged multiple specialties during planning/implementation had a greater reduction effect than ED only. The certainty of evidence for the primary outcome was very low. CONCLUSION Multidisciplinary-led interventions that provided an alternative to CT imaging were the most effective at reducing usage and did so without compromising patient safety.
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Affiliation(s)
- Cody L Dunne
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Jason L Elzinga
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Allen Vorobeichik
- Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sanjana Sudershan
- Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Diana Keto-Lambert
- Alberta SPOR SUPPORT Unit, University of Calgary, Calgary, Alberta, Canada
| | - Eddy Lang
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shawn Dowling
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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19
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Min TL, Xu L, Choi JD, Hu R, Allen JW, Reeves C, Hsu D, Duszak R, Switchenko J, Sadigh G. COVID-19 Pandemic-Associated Changes in the Acuity of Brain MRI Findings: A Secondary Analysis of Reports Using Natural Language Processing. Curr Probl Diagn Radiol 2021; 51:529-533. [PMID: 34955284 PMCID: PMC8636309 DOI: 10.1067/j.cpradiol.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 11/15/2021] [Accepted: 11/28/2021] [Indexed: 11/22/2022]
Abstract
Rationale and Objectives We aimed to assess early COVID-19 pandemic-associated changes in brain MRI examination frequency and acuity of imaging findings acuity. Methods Using a natural language processing model, we retrospectively categorized reported findings of 12,346 brain MRI examinations performed during 6-month pre-pandemic and early pandemic time periods across a large metropolitan health system into 3 acuity levels: (1) normal or near normal; (2) incidental or chronic findings not requiring a management change; and (3) new or progressive findings requiring a management change. Brain MRI frequency and imaging finding acuity level were compared over time. Results Between March and August of 2019 (pre-pandemic) and 2020 (early pandemic), our health system brain MRI examination volumes decreased 17.0% (6745 vs 5601). Comparing calendar-matched 6-month periods, the proportion of higher acuity findings increased significantly (P< 0.001) from pre-pandemic (22.5%, 43.6% and 34.0% in acuity level 1, 2, and 3, respectively) to early pandemic periods (19.1%, 40.9%, and 40.1%). During the second 3 months of the early pandemic period, as MRI volumes recovered to near baseline, the proportion of higher acuity findings remained high (42.6% vs 34.1%) compared with a similar pre-pandemic period. In a multivariable analysis, Black (B coefficient, 0.16) and underinsured population (B coefficient, 0.33) presented with higher acuity findings (P< 0.05). Conclusions As the volume of brain MRI examinations decreased during the early COVID-19 pandemic, the relative proportion of examinations with higher acuity findings increased significantly. Pandemic-related changes in patient outcomes related to reduced imaging access merits further attention.
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Affiliation(s)
- Taejin L Min
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Liyan Xu
- Department of Computer Science, Emory University(,) Atlanta, GA
| | - Jinho D Choi
- Department of Computer Science, Emory University(,) Atlanta, GA
| | - Ranliang Hu
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Jason W Allen
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Christopher Reeves
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Derek Hsu
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Richard Duszak
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Jeffrey Switchenko
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
| | - Gelareh Sadigh
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA.
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20
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Ha NT, Maxwell S, Bulsara MK, Doust J, Mcrobbie D, O'Leary P, Slavotinek J, Moorin R. Factors driving CT utilisation in tertiary hospitals: a decomposition analysis using linked administrative data in Western Australia. BMJ Open 2021; 11:e052954. [PMID: 34764174 PMCID: PMC8587703 DOI: 10.1136/bmjopen-2021-052954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES While CT scanning plays a significant role in healthcare, its increasing use has raised concerns about inappropriate use. This study investigated factors driving the changing use of CT among people admitted to tertiary hospitals in Western Australia (WA). DESIGN AND SETTING A repeated cross-sectional study of CT use in WA in 2003-2005 and 2013-2015 using linked administrative heath data at the individual patient level. PARTICIPANTS A total of 2 375 787 tertiary hospital admissions of people aged 18 years or older. MAIN OUTCOME MEASURE Rate of CT scanning per 1000 hospital admissions. METHODS A multivariable decomposition model was used to quantify the contribution of changes in patient characteristics and changes in the probability of having a CT over the study period. RESULTS The rate of CT scanning increased by 112 CT scans per 1000 admissions over the study period. Changes in the distribution of the observed patient characteristics were accounted for 62.7% of the growth in CT use. However, among unplanned admissions, changes in the distribution of patient characteristics only explained 17% of the growth in CT use, the remainder being explained by changes in the probability of having a CT scan. While the relative probability of having a CT scan generally increased over time across most observed characteristics, it reduced in young adults (-2.8%), people living in the rural/remote areas (-0.8%) and people transferred from secondary hospitals (-0.8%). CONCLUSIONS Our study highlights potential improvements in practice towards reducing medical radiation exposure in certain high risk population. Since changes in the relative probability of having a CT scan (representing changes in scope) rather than changes in the distribution of the patient characteristics (representing changes in need) explained a major proportion of the growth in CT use, this warrants more in-depth investigations in clinical practices to better inform health policies promoting appropriate use of diagnostic imaging tests.
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Affiliation(s)
- Ninh Thi Ha
- Health Economics & Data Analytics, Curtin School of Population Health, Faculty of Health Sciences, Curtin University - Bentley Campus, Perth, Western Australia, Australia
- Department of Community Health, Institute of Public Health Vietnam, Ho Chi Minh City, Viet Nam
| | - Susannah Maxwell
- Health Economics & Data Analytics, Curtin School of Population Health, Faculty of Health Sciences, Curtin University - Bentley Campus, Perth, Western Australia, Australia
| | - Max K Bulsara
- Institute for Health and Rehabilitation Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
- Centre for Health Services Research, School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Jenny Doust
- Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Donald Mcrobbie
- School of Physical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Peter O'Leary
- Faculty of Health Sciences, Curtin University, Perth, Australian Capital Territory, Australia
- Obstetrics and Gynaecology Medical School, The University of Western Australia Faculty of Health and Medical Sciences, Perth, Western Australia, Australia
| | - John Slavotinek
- South Australia Medical Imaging, Flinders Medical Centre, Bedford Park, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Rachael Moorin
- Health Economics & Data Analytics, Curtin School of Population Health, Faculty of Health Sciences, Curtin University - Bentley Campus, Perth, Western Australia, Australia
- Centre for Health Services Research, School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
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21
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Houston R, Mahato B, Odell T, Khan YR, Mahato D. The Financial and Radiation Burden of Early Reimaging in Neurosurgical Patients: An Original Study and Review of the Literature. Cureus 2021; 13:e17383. [PMID: 34584793 PMCID: PMC8457306 DOI: 10.7759/cureus.17383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 08/23/2021] [Indexed: 11/05/2022] Open
Abstract
The computed tomographic (CT) scanner has become ubiquitous in healthcare. When trauma patients are imaged at facilities not equipped to care for them, imaging is often repeated at the receiving institution. CTs have clinical, financial, and resource costs, and eliminating unnecessary imaging will benefit patients, providers, and institutions. This paper reviews patterns of repetition of CT scans for transferred trauma patients and motivations underlying such behaviors via analysis of our Trauma Registry database and literature published in this area. Neurosurgeons are fundamentally impactful in this decision-making process. The most commonly repeated scan is a CT head (CTH). More than ¼ of our patients receiving a clinically indicated repeat CTH also had a repeat scan of their cervical spine with no reason given for the cervical scan. Herein, we discuss our findings that both non-trauma center practitioners and non-neurosurgical staff at trauma centers cite a lower level of comfort with neuroradiology and fear of litigation as motivators in overzealous neuroimaging. As a result, inappropriate neurosurgical imaging is routinely ordered prior to transfer and again upon arrival at trauma centers. Education of non-neurosurgical staff is essential to prevent inappropriate neuroaxis imaging.
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Affiliation(s)
- Rebecca Houston
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
| | - Bandana Mahato
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
| | - Tiffany Odell
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
| | - Yasir R Khan
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
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22
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Sweeny A, Keijzers G, O'Dwyer J, Arendts G, Crilly J. Predictors of a long length of stay in the emergency department for older people. Intern Med J 2021; 50:572-581. [PMID: 31336021 DOI: 10.1111/imj.14441] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 07/01/2019] [Accepted: 07/18/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Dedicated geriatric models of care are becoming more prevalent due to the complexity of, and increase in, acute healthcare presentations for older patients. For older people, a long stay in the emergency department (ED) may reflect the complexity of their presentation, or deficiencies in systems that manage these complexities. AIMS To identify predictors of a long ED length of stay (LLoS) for patients ≥65 years old. METHODS Linked hospital information systems data from a large, public Australian ED were analysed in this retrospective cohort study. LLoS was defined as the 75th percentile (617 min). Multivariate regression identified LLoS predictors for admissions and discharges separately. RESULTS Of 16 791 ED presentations made by older people, 4192 experienced a LLoS; 55% were admitted. Increasing age was associated with an increasing ED LoS. Factors most predictive of LLoS for both admitted and discharged patients included: investigations (both pathology and imaging), less urgent Australasian triage scale categories and after-hours arrival. Ambulance arrival did not increase the risk of a LLoS for patients eventually admitted, but conferred nearly a twofold increased risk for a LLoS for discharged older persons (adjusted odds ratios = 1.9; 95% confidence interval 1.5-2.4). CONCLUSIONS This study assists clinicians and decision-makers to identify reasons why older persons have a LLoS, whether admitted or discharged. Interventions to streamline care for older patients arriving after-hours and who require imaging and pathology are required. LoS targets should consider age distribution. The use of ED LoS as a quality of care indicator should be assessed for admissions and discharges, separately.
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Affiliation(s)
- Amy Sweeny
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia.,School of Medicine, Bond University, Gold Coast, Queensland, Australia
| | - John O'Dwyer
- The Australian e-Health Research Centre, Health and Biosecurity, Commonwealth Scientific and Industrial Research Organisation (CSIRO), Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Glenn Arendts
- Discipline of Emergency Medicine, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Julia Crilly
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
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23
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Patient Race/Ethnicity and Diagnostic Imaging Utilization in the Emergency Department: A Systematic Review. J Am Coll Radiol 2020; 18:795-808. [PMID: 33385337 DOI: 10.1016/j.jacr.2020.12.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/11/2020] [Accepted: 12/14/2020] [Indexed: 01/27/2023]
Abstract
PURPOSE Diagnostic imaging often is a critical contributor to clinical decision making in the emergency department (ED). Racial and ethnic disparities are widely reported in many aspects of health care, and several recent studies have reported a link between patient race/ethnicity and receipt of imaging in the ED. METHODS The authors conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searching three databases (PubMed, Embase, and the Cochrane Library) through July 2020 using keywords related to diagnostic imaging, race/ethnicity, and the ED setting, including both adult and pediatric populations and excluding studies that did not control for the important confounders of disease severity and insurance status. RESULTS The search strategy identified 7,313 articles, of which 5,668 underwent title and abstract screening and 238 full-text review, leaving 42 articles meeting the inclusion criteria. Studies were predominately conducted in the United States (41), split between adult (13) and pediatric (17) populations or both (12), and spread across a variety of topics, mostly focusing on specific anatomic regions or disease processes. Most studies (30 of 42 [71.4%]) reported an association between Black, African American, Hispanic, or nonwhite race/ethnicity and decreased receipt of imaging. CONCLUSIONS Despite heterogeneity among studies, patient race/ethnicity is linked with receipt of diagnostic imaging in the ED. The strength and directionality of this association may differ by specific subpopulation and disease process, and more efforts to understand potential underlying factors are needed.
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24
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Bruls RJM, Kwee RM. Workload for radiologists during on-call hours: dramatic increase in the past 15 years. Insights Imaging 2020; 11:121. [PMID: 33226490 PMCID: PMC7683675 DOI: 10.1186/s13244-020-00925-z] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/13/2020] [Indexed: 12/15/2022] Open
Abstract
Background The objective of this study is to investigate the workload for radiologists during on-call hours and to quantify the 15-year trend in a large general hospital in Western Europe. Methods Data regarding the number of X-ray, ultrasound and computed tomography (CT) studies during on-call hours (weekdays between 6.00 p.m. and 7.00 a.m., weekends, and national holidays) between 2006 and 2020 were extracted from the picture archiving and communication system. All studies were converted into relative value units (RVUs) to estimate the on-call workload. The Mann–Kendall test was performed to assess the temporal trend. Results The total RVUs during on-call hours showed a significant increase between 2006 and 2020 (Kendall's tau-b = 0.657, p = 0.001). The overall workload in terms of RVUs during on-call hours has quadrupled. The number of X-ray studies significantly decreased (Kendall's tau-b = − 0.433, p = 0.026), whereas the number of CT studies significantly increased (Kendall's tau-b = 0.875, p < 0.001) between 2006 and 2020. CT studies which increased by more than 500% between 2006 and 2020 are CT for head trauma, brain CTA, brain CTV, chest CT (for suspected pulmonary embolism), spinal CT, neck CT, pelvic CT, and CT for suspected aortic dissection. The number of ultrasound studies did not change significantly (Kendall's tau-b = 0.202, p = 0.298). Conclusions The workload for radiologists during on-call hours increased dramatically in the past 15 years. The growing amount of CT studies is responsible for this increase. Radiologist and technician workforce should be matched to this ongoing increasing trend to avoid potential burn-out and to maintain quality and safety of radiological care.
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Affiliation(s)
- R J M Bruls
- Department of Radiology, Zuyderland Medical Center, Henri Dunantstraat 5, 6419 PC, Heerlen, The Netherlands.
| | - R M Kwee
- Department of Radiology, Zuyderland Medical Center, Henri Dunantstraat 5, 6419 PC, Heerlen, The Netherlands
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25
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Tambe J, Mbuagbaw L, Ongolo-Zogo P, Nguefack-Tsague G, Edjua A, Mbome-Njie V, Ze Minkande J. Assessing and coping with the financial burden of computed tomography utilization in Limbe, Cameroon: a sequential explanatory mixed-methods study. BMC Health Serv Res 2020; 20:981. [PMID: 33109154 PMCID: PMC7590681 DOI: 10.1186/s12913-020-05830-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 10/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There has been a significant increase in computed tomography (CT) utilization over the past two decades with the major challenges being a high exposure to ionizing radiation and rising cost. In this study we assess the risk of financial hardship after CT utilization and elaborate on how users adapt and cope in a sub-Saharan context with user fee for services and no national health insurance policy. METHODS We carried out a sequential explanatory mixed methods study with a quantitative hospital-based survey of CT users followed by in-depth interviews of some purposively selected participants who reported risk of financial hardship after CT utilization. Data was summarized using frequencies, percentages and 95% confidence intervals. Logistic regression was used in multivariable analysis to determine predictors of risk of financial hardship. Identified themes from in-depth interviews were categorized. Quantitative and qualitative findings were integrated. RESULTS A total of 372 participants were surveyed with a male to female sex ratio of 1:1.2. The mean age (standard deviation) was 52(17) years. CT scans of the head and facial bones accounted for 63% (95%CI: 59-68%) and the top three indications were suspected stroke (27% [95%CI: 22-32%]), trauma (14% [95%CI: 10-18%]) and persistent headaches (14% [95%CI: 10-18%]). Seventy-two percent (95%CI: 67-76%) of the respondents reported being at risk of financial hardship after CT utilization and predictors in the multivariable analysis were a low socioeconomic status (aOR: 0.19 [95%CI: 0.10-0.38]; p < 0.001), being unemployed or retired (aOR: 11.75 [95%CI: 2.59-53.18]; p = 0.001) and not having any form of health insurance (aOR: 3.59 [95%CI: 1.31-9.85]; p = 0.013). Coping strategies included getting financial support from family and friends, borrowing money and obtaining discounts from the hospital administration and staff. CONCLUSION No health insurance ownership, being unemployed or retired and a low socioeconomic status are associated with financial hardship after CT utilization. Diverse coping strategies are utilized to lessen the financial burden, some with negative consequences. Minimizing out-of-pocket payments and/or the direct cost of CT can reduce this financial burden and improve CT access.
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Affiliation(s)
- Joshua Tambe
- Post-Graduate School for Life Sciences, Health and Environment, The University of Yaoundé I, Yaoundé, Cameroon.
- Division of Radiology, University of Buea, Buea, Cameroon.
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, Canada
| | - Pierre Ongolo-Zogo
- Post-Graduate School for Life Sciences, Health and Environment, The University of Yaoundé I, Yaoundé, Cameroon
| | - Georges Nguefack-Tsague
- Department of Public Health, Biostatistics unit, Faculty of Medicine and Biomedical Sciences, The University of Yaoundé I, Yaoundé, Cameroon
| | - Andrew Edjua
- Higher Technical Teacher's Training College Kumba, University of Buea, Buea, Cameroon
| | | | - Jacqueline Ze Minkande
- Post-Graduate School for Life Sciences, Health and Environment, The University of Yaoundé I, Yaoundé, Cameroon
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26
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Kircher SM, Mulcahy M, Kalyan A, Weldon CB, Trosman JR, Benson AB. Telemedicine in Oncology and Reimbursement Policy During COVID-19 and Beyond. J Natl Compr Canc Netw 2020; 19:1-7. [PMID: 32998106 DOI: 10.6004/jnccn.2020.7639] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 08/13/2020] [Indexed: 11/17/2022]
Abstract
The first confirmed case of coronavirus disease 2019 (COVID-19) in the United States was reported on January 20, 2020. As of September 17, 2020, there were more than 6.6 million confirmed cases and 196,277 deaths. Limited data are available on outcomes of immunocompromised patients, but early published reports from China indicate that those with cancer have a 3.5 times higher risk of ICU admission, mechanical ventilation, or death than those without cancer. Because of the uncertain behavior of COVID-19, it has become imperative for practices to limit exposure to vulnerable patients. Telemedicine has been one of the cornerstones of caring for patients with cancer during the COVID-19 pandemic. This review provides an overview of reimbursement policy by public and private payers before and during the COVID-19 pandemic, describes implications in cancer care, and offers considerations for future reimbursement policy.
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Affiliation(s)
- Sheetal M Kircher
- 1Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago
- 2Northwestern University, Feinberg School of Medicine, Chicago; and
| | - Mary Mulcahy
- 1Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago
- 2Northwestern University, Feinberg School of Medicine, Chicago; and
| | - Aparna Kalyan
- 1Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago
- 2Northwestern University, Feinberg School of Medicine, Chicago; and
| | - Christine B Weldon
- 2Northwestern University, Feinberg School of Medicine, Chicago; and
- 3Center for Business Models in Healthcare, Glencoe, Illinois
| | - Julia R Trosman
- 2Northwestern University, Feinberg School of Medicine, Chicago; and
- 3Center for Business Models in Healthcare, Glencoe, Illinois
| | - Al B Benson
- 1Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago
- 2Northwestern University, Feinberg School of Medicine, Chicago; and
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Elzinga JL, Dunne CL, Vorobeichik A, Keto-Lambert D, Grigat D, Lang E, Dowling S. A Systematic Review Protocol to Determine the Most Effective Strategies to Reduce Computed Tomography Usage in the Emergency Department. Cureus 2020; 12:e9509. [PMID: 32884867 PMCID: PMC7461135 DOI: 10.7759/cureus.9509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 08/01/2020] [Indexed: 12/28/2022] Open
Abstract
This study describes the protocol for a systematic review and meta-analysis. The primary objective of the review is to identify experimental studies assessing the effectiveness of interventions that aim to reduce the proportion of computed tomography (CT) in emergency departments (EDs). Data permitting, our secondary objectives will be to assess the impact of reduction in CT utilization on the length of stay, admission to hospital, and uptake/satisfaction with the intervention. When available, balancing measures such as readmission to hospital or ED revisit rates will be included. Pre-defined subgroup analyses include patient populations (adult or pediatric), type of ED, and the nature of the intervention. Through this review, the research team aims to inform knowledge translation initiatives aimed at lowering CT usage in the ED by identifying the most effective interventions to safely improve CT resource stewardship.
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Affiliation(s)
| | - Cody L Dunne
- Emergency Medicine, University of Calgary, Calgary, CAN
| | | | - Diana Keto-Lambert
- Pediatrics, University of Alberta Evidence-Based Practice Center, Edmonton, CAN
| | - Daniel Grigat
- Emergency Medicine, Strategic Clinical Network, Alberta Health Services, Calgary, CAN
| | - Eddy Lang
- Emergency Medicine, University of Calgary, Calgary, CAN
| | - Shawn Dowling
- Emergency Medicine, Alberta Health Services, Calgary, CAN
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Mwinyogle AA, Bhatt A, Ogbuagu OU, Dhillon N, Sill A, Kowdley GC. Use of CT Scans for Abdominal Pain in the ED: Factors in Choice. Am Surg 2020. [DOI: 10.1177/000313482008600428] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Overutilization of healthcare resources is a threat to long-term healthcare sustainability and patient outcomes. CTis a costly but efficient means of assessing abdominal pain; however, 97 per cent of ED physicians acknowledge its overutilization. This study sought to understand factors that influence ED providers’ decision regarding CT use in the evaluation of abdominal pain. After evaluating a patient for acute abdominal pain, ED providers filled in a form in which the primary diagnosis and index of suspicion were recorded. Bivariate and multivariate analyses were used to identify predictors of outcomes. The CT scan utilization rate was 54.82 per cent. Whereas 34.11 per cent of CT scans were normal, 30 per cent yielded an acute abdominal pathology. Tenderness and rebound tenderness were positive predictors of high index of suspicion [odds ratio (OR) 2.09 and 2.54, respectively]. These variables were also predictive of obtaining a CT scan [OR 2.64 and 3.41, respectively]. Compared with whites, the index of suspicion was 26 per cent and 56 per cent less likely to be high when patients were black [OR 0.73] or Hispanic [OR 0.44] respectively. Blacks and Hispanics were less likely to have CT scans performed than whites [OR 0.58 and 0.48, respectively]. Leukocytosis significantly affected the index of suspicion for acute abdominal pathology, obtaining a CTscan and the acuity of CTscan diagnosis on multivariate analysis. Patients aged ≥60 years had 2.03 odds of acute CT finding compared with those aged <60 years. There is a need for committed efforts to optimize CT scan utilization and eliminate socioeconomic disparities in health care.
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Affiliation(s)
| | | | | | - Neer Dhillon
- St. Matthew's University School of Medicine, Orlando, Florida
| | - Anne Sill
- Saint Agnes Hospital, Baltimore, Maryland
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Low-Value Clinical Practices: Knowledge and Beliefs of Spanish Surgeons and Anesthetists. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17103556. [PMID: 32438657 PMCID: PMC7277874 DOI: 10.3390/ijerph17103556] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES: To know the frequency and causes of low value surgical practices, according to the opinion of surgeons and anesthetists, and to determine their degree of knowledge about the Spanish "Choosing wisely" initiative. METHODS: Cross-sectional observational study, based on a self-administered online questionnaire through an opportunistic sample of 370 surgeons and anesthetists from three Spanish regions, contacted through Scientific Societies. The survey took part between July and December 2017. RESULTS: A patient profile requesting unnecessary practices was identified (female, 51-65 years old and unaffiliated disease). The frequency of requests was weekly or daily for 50.0% of the professionals, of whom 15.1% acknowledged succumbing to these pressures. To dissuade the patient, clinical reasons (47%) were considered the most effective. To increase control and safety in the case was the main reason to indicate them. The greatest responsibility for overuse was attributed to physicians, defensive medicine and mass media. Assessing professionals' knowledge on unnecessary practices, an average of 5 correct answers out of 7 was obtained. Some 64.1% of the respondents were unaware of the Spanish "Choosing wisely" initiative. CONCLUSIONS: Low value surgical practices are perceived as a frequent problem, which requires an approach entailing intervention with patients and the media as well as professionals. Increase awareness on unnecessary surgical practices, and how to avoid them remain essential.
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Martín-Delgado J, Carrillo I, Mira JJ. [Outcome of complaints by patients due to the refusal of Primary Care Physicians to agree to a treatment request]. J Healthc Qual Res 2020; 35:113-116. [PMID: 32273106 DOI: 10.1016/j.jhqr.2019.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/04/2019] [Accepted: 10/08/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To analyse the frequency of complaints due to the refusal of Primary Care Physicians to indicate a diagnostic test, treatment, or referral requested by a patient. METHODS Observational, retrospective study was conducted by analysing the complaints filed in a Primary Care Area during the years 2016, 2017, and 2018. RESULTS A total of 378 complaints were included. Of these, 30 (8%) were justified in the refusal by the doctors to a request of the patient (28 addressed to general practitioners and 2 to paediatricians). The most frequent related to the request was for a treatment (18 [60%]) followed by the request for diagnostic tests (9 [30%]). While the total number of claims increased by 151%, the relative weight of the claims for not responding to a patient's request was reduced (2016, 8/70, 11.4%; 2017, 11/132, 8.3%; and 2018, 11/176, 6.3%). No professional liability claims were filed. CONCLUSIONS Complaints for rejecting patient requests increased slightly, but tends to decrease their relative weight when considering the volume of complaints.
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Affiliation(s)
- J Martín-Delgado
- Grupo de Investigación Atenea, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO)-Sant Joan d'Alacant, Alicante, España.
| | - I Carrillo
- Grupo de Investigación Atenea, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO)-Sant Joan d'Alacant, Alicante, España; Departamento de Psicología de la Salud, Universidad Miguel Hernández, Elche, Alicante, España
| | - J J Mira
- Grupo de Investigación Atenea, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO)-Sant Joan d'Alacant, Alicante, España; Departamento de Psicología de la Salud, Universidad Miguel Hernández, Elche, Alicante, España; Departamento de Salud Alicante-Sant Joan d'Alacant, Alicante, España
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Patient Factor Disparities in Imaging Follow-Up Rates After Incidental Abdominal Findings. AJR Am J Roentgenol 2019; 212:589-595. [DOI: 10.2214/ajr.18.20083] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Azman RR, Shah MNM, Ng KH. Radiation Safety in Emergency Medicine: Balancing the Benefits and Risks. Korean J Radiol 2019; 20:399-404. [PMID: 30799570 PMCID: PMC6389812 DOI: 10.3348/kjr.2018.0416] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/09/2018] [Indexed: 01/01/2023] Open
Abstract
The use of computed tomography (CT) in emergency departments has increased over several decades, as physicians increasingly depend on imaging for diagnoses. Patients and medical personnel are put at risk due to frequent exposure to and higher levels of radiation, with very little evidence of improvements in outcomes. Here, we explore why CT imaging has a tendency to be overused in emergency departments and the obstacles that medical personnel face in ensuring patient safety. The solution requires cooperation from all emergency care stakeholders as well as the continuous education of doctors on how CT scans help in particular cases.
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Affiliation(s)
- Raja Rizal Azman
- Department of Biomedical Imaging, University Malaya Research Imaging Centre (UMRIC), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Mohammad Nazri Md Shah
- Department of Biomedical Imaging, University Malaya Research Imaging Centre (UMRIC), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kwan Hoong Ng
- Department of Biomedical Imaging, University Malaya Research Imaging Centre (UMRIC), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Frumkin K, Delahanty LF. Peripheral neuropathic mimics of visceral abdominal pain: Can physical examination limit diagnostic testing? Am J Emerg Med 2018; 36:2279-2285. [PMID: 30170933 DOI: 10.1016/j.ajem.2018.08.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 08/14/2018] [Accepted: 08/15/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The emergency department evaluation of patients with abdominal pain is most appropriately directed at identifying acute inflammation, infection, obstruction, or surgical disease. Doing so commonly involves "routine" (and often extensive) diagnostic imaging and laboratory testing. Benign mimics of serious visceral abdominal pain that can be diagnosed by physical exam and confirmed with local anesthetic injections have been identified over the last century. These syndromes derive from painful irritation of the intercostal nerves by a mobile rib below, or from impingement of the cutaneous branches of those same intercostal nerves as they penetrate the abdominal wall. These peripheral neuropathic mimics of visceral abdominal pain continue to go unrecognized and underdiagnosed. METHODS Our purpose is to review the affirmative diagnosis of non-visceral abdominal pain by physical examination. RESULTS The consequences of failure to identify these conditions are considerable. In the search for a diagnosis that is literally at the provider's fingertips, patients frequently undergo months to years of fruitless and often invasive diagnostic tests, not uncommonly including unsuccessful surgeries. CONCLUSIONS With proper consideration of and appropriate testing for visceral etiologies, a carefully directed physical examination may yield an affirmative diagnosis in a percentage of these common emergency department patients.
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Affiliation(s)
- Kenneth Frumkin
- Emergency Medicine Department, Naval Medical Center, Portsmouth, VA, USA.
| | - Liam F Delahanty
- Emergency Medicine Department, Naval Medical Center, Portsmouth, VA, USA
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Baloescu C. Diagnostic Imaging in Emergency Medicine: How Much Is Too Much? Ann Emerg Med 2018; 72:637-643. [PMID: 30146444 DOI: 10.1016/j.annemergmed.2018.06.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Indexed: 01/11/2023]
Affiliation(s)
- Cristiana Baloescu
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT.
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