Computed Tomography Scan Utilization in Emergency Departments: A Multi-State Analysis

doi:10.1016/j.jemermed.2010.06.030

The Journal of Emergency Medicine

Volume 41, Issue 3, September 2011, Pages 302-309

https://doi.org/10.1016/j.jemermed.2010.06.030 Get rights and content

Abstract

Background

Increased utilization of computed tomography (CT) in emergency departments (EDs) has become a concern due to its expense and the potential risks associated with radiation exposure.

Objective

To describe the predictors of CT utilization based on patient, provider, and ED characteristics.

Methods

There were 3,217,396 ED patient visits during a 12-month period that were included in this retrospective analysis of a database from a single billing company that included 227 EDs in 41 states. Data were collected between January 1, 2006 and December 31, 2006 and included patient visit information, CT use for each patient visit, patient demographics, ED provider information, and ED volume.

Results

The CT utilization rate was 16.7% (95% confidence interval [CI] 16.7–16.8%) for adults, whereas in pediatric patients (< 18 years of age) it was 5.3% (95% CI 5.3–5.4%). The adult CT utilization rate ranged from 11.3% (95% CI 11.2–11.4%) at age 20–29 years to 24.6% (95% CI 24.5–24.8%) for those > 65 years of age. For the admitted patients, the CT utilization rate was 27.8% (95% CI 27.6–27.9%); for the patients transferred out of the hospital, the CT utilization rate was 23.2% (95% CI 22.9–23.6%). Discharged patients had a rate of 11.3% (95% CI 11.2–11.3%) and patients who left against medical advice had a scan rate of 20.2% (95% CI 19.6–20.7%). The CT utilization rate was 9.3% (95% CI 9.2–9.4%) in EDs with < 20,000 annual visits and increased to 17.8% (95% CI 17.7–17.9%) in EDs with volumes of > 40,000. The CT utilization rate was 16.1% (95% CI 16.1–16.2%) for emergency medicine boarded physicians vs. 11.3% (95% CI 11.3–11.4%) for non-emergency-medicine boarded physicians.

Conclusions

CT utilization by EDs seems to vary by a number of parameters, including patient age, ED volume, training background of the provider, and disposition status of the patient.

Introduction

Computed tomography (CT) scan is a commonly used diagnostic study in the emergency department (ED) due to its ready accessibility and diagnostic accuracy. However, there are increasing concerns that the study is both expensive and has significant risks associated with radiation exposure. With the national cost of health care expenditures reaching 16% of the gross national product in 2007, much effort has been invested in proper resource utilization (1). Although awareness of the risks of CT scans has increased, the number of CT scans ordered or performed in the ED has grown by 200–400% over 5 years in both adult and pediatric populations 2, 3. Whereas utilization has increased, studies have shown that important clinical findings (the diagnostic sensitivity and specificity of the examination) have decreased 4, 5, 6.

There are also significant concerns about the long-term risk of radiation exposure from CT scans 7, 8, 9, 10. This concern is particularly amplified in the pediatric population because children are at greater risk for the long-term consequences of exposure to ionizing radiation (11). Studies have demonstrated that there is a lack of awareness among radiologists, pediatricians, and emergency physicians about the risk of radiation exposure (12).

Clinical decision rules have been developed for specific patient conditions, such as minor head trauma and cervical spine injuries, in an effort to avoid potential over-utilization of CT scans 13, 14, 15, 16. But these efforts to reduce CT utilization are compromised by the legal climate and the increasing capacity of CT scans to provide critical diagnostic information in a time-sensitive manner for an increasing number of conditions (17). Further compounding these efforts is a lack of understanding of the actual usage patterns of CT scans in a variety of clinical settings, including EDs.

The goal of this study was to provide a better understanding of CT utilization in a wide range of ED settings and to characterize utilization by examining several parameters, including patient information as well as ED and provider characteristics.

Section snippets

Materials and Methods

The study was performed using a retrospective review of billing records from a single national, multi-specialty billing company over a 12-month period. A total of 227 EDs in 41 states were included. These EDs included those from for-profit and non-profit community hospitals, with and without residency training programs, as well as some university-based academic departments. Geographic locations included urban, suburban, and rural hospitals. Annual ED patient volumes ranged from < 1000 to > 50,000.

Results

All patient visits that occurred between January 1, 2006 and December 31, 2006 were included in the study. A total of 3,217,396 ED patient visits were reviewed for patient demographics, ED disposition, and CT use, but the specific type of CT was not listed. Of the 227 EDs, 64 had < 20,000 annual visits, 137 had 20,000–40,000 annual visits, and 26 had > 40,000 annual visits. There were a total of 742,729 pediatric (< 18 years old) ED patient visits. Of the total, 62,190 (1.9%) patient visits were

Discussion

The goal of this study was to describe predictors of CT utilization in EDs based on ED, patient, and provider characteristics. Prior ED-based CT utilization studies have been generally limited to a single hospital, or the National Hospital Ambulatory Medical Care Survey (NHAMCS), which has a more rigorous sampling frame but has limited information on predictors. To our knowledge, no prior studies have assessed the characteristics of the ordering physician.

The data collected in our study are

Conclusions

CT utilization in EDs seems to vary by a number of parameters, including patient age, ED volume, training background of the provider, and disposition status of the patient. According to the data from this study, EM-boarded physicians were more likely to order CT scans on patients compared to their non-EM-boarded colleagues. Older patients were more likely to receive a CT scan compared to younger patients, and EDs with a larger volume tended to have a greater CT utilization compared to

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Single institutional, retrospective review of 367 CT scans of the neck performed for the evaluation of throat pain in the ED from August 2013 to September 2019. Patients' clinical history, physical exams, lab findings, and imaging results were recorded.
A total of 367 CT scans of the neck performed for the evaluation of throat pain included a recorded exam and clinical history. Of these cases, we noted that the presence of cervical lymphadenopathy (OR = 2.69; 95% CI, 1.37–5.49), tonsillar findings (OR = 2.94; 95% CI, 1.4–6.57), increased white blood cell count (OR = 1.08; 95% CI, 1.02–1.15), and temperature (OR = 1.94; 95% CI, 1.1–3.6) were associated with increased likelihood of obtaining a diagnostic CT scan.
Consideration of tonsillar abnormalities, lymphadenopathy, body temperature, and measured leukocyte count prior to ordering CT scans of the neck for throat pain may increase the diagnostic yield of such exams and decrease CT utilization in the ED.
National Trends in Imaging Rates for Eye-Related Emergency Department Visits in the United States
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To identify nationwide trends and factors associated with advanced imaging (computed tomography [CT] and magnetic resonance imaging [MRI]) use for eye-related emergency department (ED) visits.
Retrospective, trend study.
Setting: National Hospital Ambulatory Medical Care Survey 2007-2015. Patient Population: Eye-related ED patients who underwent CT or MRI. Main Outcome Measure(s): Population-based CT/MR imaging rates and independent factors associated with imaging.
An estimated 7 million eye-related ED visits occurred between 2007 and 2015. Adjusted for annual eye-related ED visits, the rate of imaging use rose 94%, from 121.7 per 1,000 eye-related ED visits in 2007 to 236.0 per 1,000 eye-related ED visits in 2015. Visual disturbances, contusion of the eye and/or adnexa, open globes and open wounds of ocular adnexa, diplopia, superficial corneal and/or conjunctival injuries, and orbital fractures accounted for 73.2% of all visits where imaging was performed. On multivariable analysis, older patients (odds ratio [OR] = 1.02, 95% confidence interval [CI] 1.01-1.03) and females (OR=2.07, 95% CI 1.18-3.63) were more likely to undergo imaging than younger patients and males. Imaging was also more likely to be performed for Medicare beneficiaries (OR=2.12, 95% CI 1.08-4.15) than for privately insured patients. Patients who were admitted to the hospital were 6 times more likely (OR=6.39, 95% CI 2.04-20.0) to undergo imaging than those who were not admitted.
Advanced imaging for eye-related ED visits has escalated at a higher rate than ED visits for eye complaints. Future studies to develop evidence-based algorithms for use of CT/MR imaging for eye complaints that can help balance benefits against financial costs and health risk are warranted.
Impact of Referring Hospital Imaging on Mortality at a Level I Trauma Center
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In the past 2 decades, substantial effort has been directed toward creating and improving regional trauma systems to streamline the triage and transportation of patients with trauma.1-6 Concurrently, the availability of computed tomography (CT) in RHs has steadily increased since the 1980s.7-10 With advancing technology and rapidly increasing availability, CT has become a standard radiologic adjunct in the evaluation of a patient with trauma.9,10
Computed tomography (CT) has become a standard adjunct in the evaluation of patients with trauma. However, utility of imaging at the referring hospital remains controversial. We study the effect of CT scans at referring hospitals on in-hospital mortality at a receiving trauma center.
A retrospective cohort study was performed with adult patients with severe trauma transferred to a level I trauma center from regional nontrauma hospitals between 2012 and 2017. Baseline characteristics were compared with Student's t-test and Pearson's chi-squared testing. The primary endpoint was in-hospital mortality. Cox regression, controlling for transfer time, was used to evaluate the effect of imaging on mortality.
Three thousand four hundred and fifteen adult patients with trauma were included: 1135 (33.2%) received a pretransfer CT scan, whereas 2280 (66.8%) did not. Patients who received a pretransfer CT scan were more likely to be older, female, white, have a higher Charlson Comorbidity Index, less severely injured, have a blunt mechanism, and be transferred by ground. There was no difference in distance (58.3 miles versus 57.0 miles, P = 0.34), but transfer times were significantly increased for those who received pretransfer scans (288 versus 213 min, P < 0.005). The adjusted model controlling for multiple variables has a hazard ratio of 0.533 (95% confidence interval 0.42-0.68, P < 0.005).
There is a survival advantage for patients who receive pretransfer CT scans despite having significantly longer transport times. We suggest that this decreased mortality associated with pretransfer imaging may reflect improving trends in referring physician transfer decisions.
Factors Affecting Emergency Department Computed Tomography Use in Children
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Citation Excerpt :
Use of this practice would allow for lower overall CT use as some of the patients admitted and observed will improve and will not undergo CT scan. The inverse relationship of pediatric ED volume and CT scanning at the higher volume EDs is in contrast to a previous study that found an increasing CT rate with increasing volume.21 However, that study used total volume (adult and pediatric) rather than evaluating pediatric volume specifically, which is likely a better surrogate for the availability of pediatric-focused resources which can affect CT scan utilization.
Variability in computed tomography (CT) use during pediatric emergency department (ED) visits has been reported. Our objective was to identify patient and hospital characteristics associated with CT use during pediatric ED visits.
Patients <18 y treated and released from EDs in the 2006-2012 Nationwide Emergency Department Sample were included. Associations were evaluated between pediatric CT scan rate and patient/hospital factors using logistic mixed effects models. Independent predictors of being a high outlier (having a pediatric CT scan rate in the top 10%) were also evaluated using logistic regression models.
There were 1543 EDs and 20,703,273 visits included. CT scans were prescribed in 4.7% of pediatric ED visits; the highest 10% of EDs prescribed CT scans in >7.63% of all pediatric visits. In multivariable analysis, older age, male gender, private insurance, higher zip code level median income, and higher injury severity were all associated with an increased probability of receiving a CT scan (all P < 0.001). The chance of receiving a CT scan also varied by diagnosis and was independently associated with geographic location and annual pediatric ED volume. Rates of CT use increased with increasing pediatric volume up to approximately 5400 annual pediatric visits, and then decreased with volume >5400 annual visits.
Several patient-level and ED-level characteristics, including annual pediatric volume, are associated with the probability of a child having a CT scan during an ED visit. Future work should focus on determining drivers behind these associations to develop intervention strategies to decrease pediatric CT use.
Injured Children Receive Twice the Radiation Dose at Nonpediatric Trauma Centers Compared With Pediatric Trauma Centers
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Citation Excerpt :
CT use in children has increased, due in part to increasing concussion concerns, paralleled by emergency department (ED) visits [1-3].
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To compare the radiation exposure injured children receive when imaged at nonpediatric hospitals (NPHs) versus pediatric hospitals.
Injured children younger than 18 years who received a CT scan at a referring hospital during calendar years (CYs) 2010 and 2013 were included. Patient-level factors included demographics, mode of transportation, and Injury Severity Score, and hospital-level factors included region of state, radiology services, and hospital type and size. Our primary outcome of interest was the effective radiation dose.
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Computed tomography (CT) is a useful and necessary part of many emergency department (ED) assessments. However, the costs of imaging and the health risks associated with radiation exposure have sparked national efforts to reduce CT ordering in EDs.
We analyzed CT ordering habits prior to and following implementation of a feedback tool at a community hospital.
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We examined the records of 104,454 patients seen between October 1, 2013 and December 31, 2014. There were 5552 or 21.0% of patients seen during the baseline period that underwent CT imaging. We observed an absolute reduction in imaging of 2.3% (95% confidence interval 1.7–2.8%) after implementation, avoiding approximately $400,000 in costs, 22 days of scanning time, and radiation exposure equivalent to 33,000 chest films annually. These changes occurred across physicians and mid-level providers, regardless of the number years of practice or board certification.
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Administration of Emergency MedicineComputed Tomography Scan Utilization in Emergency Departments: A Multi-State Analysis

Abstract

Background

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Materials and Methods

Results

Discussion

Conclusions

Acad Radiol

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Health spending projections through 2016: modest changes obscure part D’s impact

Health Aff (Millwood)

Increasing utilization of computer tomography in the pediatric emergency department, 2000–2006

Emerg Radiol

Increasing utilization of computed tomography in the adult emergency department, 2000–2005

Emerg Radiol

CT pulmonary angiography: a comparative analysis of the utilization patterns in emergency department and hospitalized patients between 1998 and 2003

AJR Am J Roentgenol

Utilization patterns and diagnostic yield of 3421 consecutive multidetector row computed tomography pulmonary angiograms in a busy emergency department

J Comput Assist Tomogr

Cancer risks attributable to low doses of ionizing radiation: assessing what we really know

Proc Natl Acad Sci U S A

Radiation exposure from diagnostic imaging in severely injured trauma patients

J Trauma

Computed tomography—an increasing source of radiation exposure

N Engl J Med

Estimated risks of radiation induced fatal cancer from pediatric CT

AJR Am J Roentgenol

Administration of Emergency Medicine
Computed Tomography Scan Utilization in Emergency Departments: A Multi-State Analysis