Are all after-hours diagnostic imaging appropriate? An Australian Emergency Department pilot study

Measuring appropriateness of diagnostic imaging: a scoping review

In radiology, the justification of diagnostic imaging is a key performance indicator. To date, specific recommendations on the measurement of appropriateness in diagnostic imaging are missing. To map the study literature concerning the definition, measures, methods and data used for analyses of appropriateness in research of diagnostic imaging. We conducted a scoping review in Medline, EMBASE, Scopus and the Cochrane Central Register of Controlled Trials. Two independent reviewers undertook screening and data extraction. After screening 6021 records, we included 50 studies. National guidelines (n = 22/50) or American College of Radiology Appropriateness Criteria (n = 23/50) were used to define and rate appropriateness. 22/50 studies did not provide methodological details about the appropriateness assessment. The included studies varied concerning modality, amount of reviewed examinations (88-13,941) and body regions. Computed tomography (27 studies, 27,168 examinations) was the most frequently analyzed modality, followed by magnetic resonance imaging (17 studies, 6559 examinations) and radiography (10 studies, 7095 examinations). Heterogeneous appropriateness rates throughout single studies (0-100%), modalities, and body regions (17-95%) were found. Research on pediatric and outpatient imaging was sparse. Multicentric, methodologically robust and indication-oriented studies would strengthen appropriateness research in diagnostic imaging and help to develop reliable key performance indicators.

Appropriateness of Head CT Scans at Tikur Anbessa Specialized Hospital, Ethiopia

Background

Overutilization of advanced diagnostic imaging modalities strains health care systems, especially in resource limited setups. The aim of this study is to identify magnitude of inappropriate Head Computed Tomography scans at Tikur Anbessa Specialized Hospital.

Methods

Retrospective cross-sectional study was conducted at Tikur Anbessa Specialized Hospital, Radiology department, among patients getting Head Computed Tomography examinations in the period of August 2018- November 2018. Appropriateness of each scan was assessed using the American College of Radiology Appropriateness Criteria.

Result

Of the 443 Head Computed Tomography scans assessed, 61.6% were done for male patients and the mean age of patients scanned is 35. Children younger than 14yrs of age constituted 17.2%. No contrast was used in 63.9% of the scans and 64.3% were initial imaging with no prior study for similar indication. Out of the scans evaluated, 11.7% were inappropriate. Headache (38.5%), Seizure (23.1%) and Head trauma (23.1%) were the commonest indications for inappropriate scan. Scans done for cerebrovascular disease were 240 times more likely to be appropriate. Large number of inappropriate scans were requested from central triage (33.3%) and adult emergency (26.2%). Pediatric department requested inapproprieate scans in 11.9% of the cases. Residents requested majority of inappropriate scans (82.3%). Inappropriateness was associated with use of contrast agent and having only incidental outcomes.

Conclusion

A large number of inappropriate Head Computed Tomography scans are being done. Mechanisms such as preauthorization by radiologists, increasing awareness by medical students, physicians, radiology residents and radiologists and preparing customized imaging appropriateness guidelines should be implemented.

Does shifting to professional emergency department staffing affect the decision for chest radiography?

BACKGROUND

The study aims to determine whether shifting to professional emergency department (ED) teams leads to a higher rate of radiologic workup.

METHODS

We retrospectively analyzed a total of 2,000 patients presenting to the ED of a tertiary teaching hospital in two time periods: group 1 (G1) comprised 1,000 consecutive patients enrolled from December 21, 2012 to January 5, 2013 (all patients were examined by an internal medicine specialist); group 2 (G2) comprised 1,000 consecutive patients enrolled from December 21, 2018 to January 3, 2019 (all patients were examined by an emergency physician).

RESULTS

The chest X-ray (CXR) was performed in 40.6% of all patients. There was no difference in the frequency of CXR (38.9% in G1 vs. 42.3% in G2, P=0.152). More CXRs were performed in G2 patients older than 65 years, in female patients older than 65 years, in patients presenting during the evening and night shifts or off-hours, in patients with a history of malignancy, in patients with gastrointestinal bleeding, and in patients with bradycardia, but fewer in patients presenting with arrhythmia. No difference in the rates of pathological CXR was found (47.3% in G1 vs. 52.2% in G2, P=0.186). Compared with G2, higher sensitivity and specificity were obtained for the binary logistic regression model predicting pathological findings in G1.

CONCLUSIONS

Shifting to professional ED teams does not increase radiologic workup. By implementing deliberate usage of ultrasound, some self-governing procedures, case-oriented investigations, and center-specific recommendations, unnecessary radiologic workup can be avoided. Professional ED teams could lead to a higher standard of emergency care.

Determining the Need for After-Hours Diagnostic Radiological Reporting in Emergency Departments at Public Hospitals in South Africa: Perceptions of Emergency Physicians in KwaZulu-Natal

BACKGROUND

Emergency departments in South African public hospitals have a high patient load after hours, with inadequate numbers of health care professionals available to satisfy patient influx. In addition, there is often no provision of after-hours diagnostic reporting services in public hospitals, to an extent that the emergency physician is responsible for interpreting all radiographic images requested themseves. Emergency physicians, in this study, can be described as any medical doctor registered with the Health Professions Council of South Africa and working in the emergency department as a registrar or consultant physician because there were no physicians specialized in emergency medicine working at the hospitals selected for this study.

AIM

The aim of this study was to determine the views of emergency physicians on whether there is a need for an after-hours diagnostic radiological reporting service in selected public hospitals in KwaZulu-Natal Province, South Africa.

METHODS

A descriptive cross-sectional quantitative research design was utilized, through means of a survey, to assess the emergency physicians' perceptions regarding the need for after-hours diagnostic radiological reporting. In addition, the study used a descriptive quantitative research design to record the number of conventional diagnostic radiographic examinations performed at the selected hospitals, after hours, and the proportional number of these radiographic examinations that were reported on by radiologists during office hours, the following day. The distribution of questionnaires and data collection, with regard to the number of examinations reported on, and those not reported on, were carried out simultaneously during the execution of this study. The study was conducted over a three-month period in 2017, at four public hospitals in KwaZulu-Natal-one of the nine provinces of South Africa.

RESULTS

This study found that, during the study period, between 0.1% and 0.6% of the conventional diagnostic radiographic examinations performed, after hours, were reported on by radiologists during office hours, the following day. The surveyed emergency physicians felt that the interpretation of diagnostic images took up valuable time that could be spent on patient management, and there was near-total agreement, whereby 92% (n = 36) of the physicians would have preferred after-hours reporting to be performed by a radiologist. Physicians agreed that having a radiologist or reporting radiographer to provide radiological reports would allow for more effective and efficient patient management.

CONCLUSION

The results of this study indicated that there is a need for after-hours radiographic reporting at the selected public hospitals and for the further training of emergency physicians in radiographic image interpretation. Based on the findings of this study, it is recommended that after-hours radiological reporting services be considered for public hospitals and that courses be offered to emergency physicians on the interpretation of diagnostic radiographic images. A hospital policy review may therefore be needed to adjust the focus of hospitals toward reducing the workload of emergency physicians, wherever possible, such as by incorporating support services like radiographic reporting and by providing further training on the interpretation of diagnostic radiographic images, which will both act to reduce the potential risk of misdiagnosis.

To what extent do hospitalised patients receive appropriate CT and MRI scans? Results of a cross-sectional study in Southern Italy

OBJECTIVES

The aim of this study was to assess the frequency of appropriateness of inpatient CT and MRI scans performed in Southern Italy.

METHODS

The study was carried out by retrospectively reviewing medical records of adult patients admitted between 1 January and 31 December 2012 in two hospitals. The evaluation of appropriateness was performed according to the American College of Radiology Appropriateness Criteria, which assigns a score between 1 and 9.

RESULTS

Eight hundred and fifty-three medical records were reviewed. Six hundred and thirty-nine patients received CT examinations and 256 received MRI examinations. Four hundred and ninety-six (77.6%) of the patient population had appropriate CT and 202 (78.9%) received appropriate MRI examinations. The appropriateness was associated with: a confirmation of the diagnostic hypothesis, only one examination performed during hospital stay, the anatomical scan region, with musculoskeletal system being the least appropriate anatomical scan region. Moreover, for CT examinations, appropriateness was also associated with no use of contrast agent.

CONCLUSIONS

Our findings highlight the need to reduce inappropriate use of CT and MRI. The study showed that the tool used is reliable to measure the extent of appropriateness of diagnostic imaging for inpatient examinations.