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Use of CT Scans for Abdominal Pain in the ED: Factors in Choice
Abstract
Overutilization of healthcare resources is a threat to long-term healthcare sustainability and patient outcomes. CT is 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 CT scan and the acuity of CT scan 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.
... 5 There are no objective signs, symptoms, standards or lab tests that can perfectly determine the need for CT. 6 In this context, individual clinical judgment and local practice patterns can determine which patients receive these tests and may engender disparate care between Black and White patients. 6,7 Prior research on the national scale provides adequate evidence suggesting minoritized populations receive significantly less imaging overall compared to their White counterparts. 8,9 Given known disparities in the assessment and treatment of pain for Black patients, there may be disparities in imaging based on a chief complaint of abdominal pain because there are no guidelines for the management of acute, geriatric abdominal pain. ...
... 6,10,11 A cohort of ED patients at a single institution provides suggestive evidence of such an effect: Black and Hispanic adults (≥18) with abdominal pain were significantly less likely to receive CT than their White counterparts. 7 There is currently a paucity of studies assessing the racial disparities in imaging in abdominal pain in older adults. In this study we used nationally representative data to examine patterns of cross-sectional imaging for abdominal pain presentations among older adults in US EDs. ...
... Our study builds on prior work demonstrating a racial disparity in abdominal imaging utilization in a single hospital's ED for abdominal pain. 5,7 It also adds to a greater body of evidence identifying racial disparities in imaging in the ED, specifically among older adults. There are no other national studies that focus on this specific age group with abdominal pain. ...
Introduction: Abdominal pain is the leading emergency department (ED) chief complaint in older (≥65 years of age) adults, accounting for 1.4 million ED visits annually. Ultrasound and computed tomography (CT) are high-yield tests that offer rapid and accurate diagnosis for the most clinically significant causes of abdominal pain. In this study we used nationally representative data to examine racial/ethnic differences in cross-sectional imaging for older adults presenting to the ED with abdominal pain. Methods: We performed a retrospective, cross-sectional analysis using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to assess differences in the rate of imaging between White and Black older adults presenting to the ED for abdominal pain. Our primary outcome was the receipt of abdominal CT and/or ultrasound imaging. Results: Across 1,656 older adult ED visits for abdominal pain, White patients were 26.8% (relatively, 14.2% absolute) more likely to receive abdominal CT and/or ultrasound than Black patients: 802 of 1,197 (67.0%) White patients were 26.8% (relatively, 14.2% absolute) more likely to receive abdominal computed tomography and/ or ultrasound than Black patients (P=0.01). Conclusion: This study revealed that Black older adults presenting to the ED with abdominal pain receive significantly lower levels of cross-sectional imaging (CT/ultrasound) than White patients. Our findings highlight the need for further investigations into causes of disparities while initiating quality improvement processes to assess and address site- and clinician-specific patterns of care.
... In recent years, the use of computed tomography (CT) scans has become a crucial tool in diagnosing various medical conditions in pediatric populations. Specifically, abdomenpelvis CT scans have proven to be invaluable in detecting and evaluating a wide range of diseases (Mwinyogle et al., 2020). However, as the utilization of pediatric CT scans has increased, concerns regarding the potential cancer risk associated with this imaging modality have emerged (Fahimi et al., 2012). ...
Introduction: The aim of this study is to assess the organ doses, effective dose, image quality, and the potential risk of developing radiation-related cancer in children undergoing computed tomography (CT) scans of the abdomen-pelvis. Methods: The research involved 219 pediatric patients (129 males and 90 females) who underwent an abdomen-pelvic CT examination. The patients were categorized into four age groups: <1, 1-4, 5-9, and 10-14 years old. The NCICT software version 3.0 was utilized to estimate the organ doses and effective dose. Estimation of cancer incidence risks were conducted according to the Biological Effects of Ionizing Radiation (BEIR) VII report. The image quality was evaluated by measuring the level of noise, as well as the signal-to-noise ratio, and contrast-to-noise ratio. Results: The colon received the highest organ dose in all age groups. The risk of all cancers was 75.38 per 100,000 for the <1 age group, and it decreased to 56.10 for the 10-14 age group. The cancer risks were statistically higher for females (p < 0.05). The mean noise values for the liver, aorta, and paraspinal muscle were found to be 9.08, 11.04, and 8.21, respectively. Conclusion: The findings of present study indicate that pediatric abdomen-pelvis CT examinations carry a potential risk of cancer that should not be disregarded. Consequently, it is crucial to prioritize radiation protection measures in children compared to adults.
... 15 Furthermore, many abdominal CTs are interpreted by radiologists as normal (one study reported that 34% of CTs obtained during emergency department visits were "normal"). 16 Recent breakthroughs in automated CT image segmentation using deep-learning allow for rapid calculation of body composition measures on large populations. [17][18][19][20][21] This "opportunistic screening" offers the ability to gain further information about patient health beyond the indications for which the CT imaging was clinically ordered. ...
Background
Body composition can be accurately quantified from abdominal CT exams and is a predictor for the development of aging-related conditions and for mortality. However, reference ranges for CT-derived body composition measures of obesity, sarcopenia, and bone loss have yet to be defined in the general population.
Methods
We identified a population-representative sample of 4,900 persons aged 20 to 89 years who underwent an abdominal CT exam from 2010 to 2020. The sample was constructed using propensity score matching to an age and sex stratified sample of persons residing in the 27-county region of Southern Minnesota and Western Wisconsin. The matching included race, ethnicity, education level, region of residence and the presence of 20 chronic conditions. We used a validated deep learning based algorithm to calculate subcutaneous adipose tissue area, visceral adipose tissue area, skeletal muscle area, skeletal muscle density, vertebral bone area, and vertebral bone density from a CT abdominal section.
Results
We report CT-based body composition reference ranges on 4,649 persons representative of our geographic region. Older age was associated with a decrease in skeletal muscle area and density, and an increase in visceral adiposity. All chronic conditions were associated with a statistically significant difference in at least one body composition biomarker. The presence of a chronic condition was generally associated with greater subcutaneous and visceral adiposity, and lower muscle density and vertebrae bone density.
Conclusions
We report reference ranges for CT-based body composition biomarkers in a population-representative cohort of 4,649 persons by age, sex, body mass index, and chronic conditions.
... Despite CT scan resulting in the correct clinical diagnosis up to 87% of the time of patients with non-traumatic abdominal pain in the emergency department, 38 it is currently utilized for only about 54% of patients presenting with these symptoms. 39 Increase utilization of CT scan in patients with abdominal pain and relevant risk factors could be 1 way to decrease the incidence of missed AAA and aortic dissections in the emergency department. As reflected with a higher prevalence of "other CV misdiagnosis" for aortic dissections, initial misdiagnosis of acute myocardial infarction in patients with dissections also remains a concern. ...
Objective
Aortic aneurysms and dissections are prevalent causes of morbidity and mortality. The management of aortic pathologies may be called into question in malpractice suits. Malpractice claims were analyzed to understand common reasons for litigation, medical specialties involved, patient injuries, and outcomes.
Methods
Litigation cases in the Westlaw database from September 1st, 1987 to October 23 rd, 2019 were analyzed. Search terms included “aortic aneurysm” and “aortic dissection.” Data on plaintiff, defendant, litigation claims, patient injuries, misdiagnoses, and case outcomes were collected and compared for aortic aneurysms, aortic dissections, and overall cases.
Results
A total of 346 cases were identified, 196 involving aortic aneurysms and 150 aortic dissections. Physician defendants were emergency medicine (29%), cardiology (20%), internal medicine (14%), radiology (11%), cardiothoracic (10%) and vascular surgery (10%). Litigation claims included “failure to diagnose and treat” (61%), “delayed diagnosis and treatment” (21%), “post-operative complications after open repair” (10%) and “negligent post-operative care” (10%). Patients with aneurysms presented with abdominal (63%) and back pain (37%), while dissections presented with chest pain (78%), abdominal pain (15%), and shortness of breath (14%). Misdiagnoses included gastrointestinal (12%), other cardiovascular (9%), and musculoskeletal conditions (9%), but many were not specified (58%). Overall, 83% of cases were wrongful death suits. Injuries included loss of consortium (23%), emotional distress (19%), and bleeding (17%). In 53% of the cases, the jury ruled in favor of the defendant. 25% of cases ruled for the plaintiff. 22% of cases resulted in a settlement. The mean rewarded for each case was 5,939,134.58; Range: 68,035,462).
Conclusion
For aortic pathologies, post-operative complications were not prominent among the reasons why suits were brought forth. This suggests improvements in education across all involved medical specialties may allow for improved diagnostic accuracy and efficient treatment, which could then translate to a decrease in associated litigation cases.
... Six studies used data from large-scale national databases including NHAMCS (4), the Premier Healthcare Alliance database, and the American College of Surgeons National Trauma Data Bank. Three studies examined topics related to abdominal pain, two of which determined that black or Hispanic patients had lower odds of undergoing CT [37,38], the third finding that for symptoms related to renal colic, Hispanic patients were more likely to undergo CT [32]. On the topic of chest pain, 2 studies determined that black and African American patients were less likely to undergo imaging (chest radiography or echocardiography) [7,39], while for stroke, 2 studies did not find an association with race/ethnicity [40,41]. ...
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.
To assess the noninferiority of MRI diagnostic accuracy to CT scan as a second-line examination of acute/subacute abdominopelvic pain in a population of young women after an inconclusive ultrasound (US).
This prospective, multicenter non-inferiority study included 18–40-year-old non-pregnant women with non-traumatic acute/subacute abdominal pain. They had an inconclusive US warranting the prescription of an additional CT scan. Within 6 h of the CT, all these women underwent abdomino-pelvic MRI. A retrospective reading of the CT and MR provided a diagnosis using a standardized list. The gold standard diagnosis, based on a 3-month follow-up, was done by a panel of experts. Statistical analysis was conducted to assess the noninferiority of the diagnostic accuracy of MRI compared to that of CT. The noninferiority margin was set at 10%. Inter-observer agreement and diagnostic performance of a conditional imaging strategy were estimated.
133 participants were analyzed (median: 27 years). The most common diagnoses were non-specific pain (30.1%), ovarian cyst rupture (12.8%), and appendicitis (9.7%). MRI demonstrated non-inferiority diagnostic accuracy estimated between 60.9% (81/133) and 88% (117/133) compared to CT, estimated between 64.7% (86/133) and 83.5% (111/133). The conditional imaging strategy (MRI, followed by CT when the MRI was normal) had a diagnostic accuracy of 91%.
MRI diagnostic performances are not inferior to CT for acute abdominal pain in women aged 18–40. A conditional imaging strategy based on MRI would give an accuracy of 91% and might be considered a second-line imaging modality in that context.
Question Can MRI serve as an alternative to CT as a second-line imaging modality for acute abdominopelvic pain in young women (18–40) after an inconclusive ultrasound?
Findings MRI accuracy after inconclusive US ranged from 60.9 to 88%. A conditional strategy (MRI first, CT if normal) reached 91% accuracy, avoiding 59% of CTs.
Clinical relevance MRI is not inferior to CT for diagnosing uncategorized causes of acute abdomino-pelvic pain in young non-pregnant women. A conditional imaging strategy based on MRI as a second-line imaging modality would give an accuracy of 91%.
Objectives
Abdominal pain is the most common reason for visit (RFV) to the emergency department (ED) for adults, yet no standardized diagnostic pathway exists for abdominal pain. Optimal management is age‐specific; symptoms, diagnoses, and prognoses differ between young and old adults. Availability and knowledge of the effectiveness of various imaging modalities have also changed over time. We compared diagnostic imaging rates for younger versus older adults to identify practice patterns of abdominal imaging across age groups over time.
Methods
We analyzed weighted, nationally representative data from the National Hospital Ambulatory Medical Care Survey 2007–2019 for adult ED visits with a primary RFV of abdominal pain. We included 23,364 sampled visits, representing 123 million visits.
Results
From 2007 to 2019, total visits increased for ages 18–45 ( p < 0.001), 46–64 ( p < 0.001), and 65+ ( p = 0.032). The percentage of visits with primary RFV of abdominal pain increased from 9.4% to 11.6% for ages 18–45, 7.8%–9.0% for ages 46–64, and 6.0%–6.5% for 65+. Computed tomography (CT) scan rates increased over time from 26.2% of all patients receiving a CT scan to 42.6%. Relative percentage change in abdominal CT scans was greatest for older adults, with a 30.3% increase, compared to 24.0% for middle‐aged adults and 15.0% for young adults. Test positivity, defined as receiving an emergency general surgical diagnosis after CT or ultrasound, increased from 17.2% in 2007 to 22.9% in 2019 ( p < 0.01). Of the older adults with abdominal pain in 2019, 13% received an X‐ray only, which is neither sensitive nor specific for acute pathology in older adults.
Conclusions
Despite more abdominal pain ED visits and increased imaging rates per visit, test positivity continues to rise. Our findings do not support claims that CT and ultrasound are being used less appropriately over time, but demonstrate widespread use of X‐rays, which are potentially ineffective for abdominal pain.
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.
Background:
Acute appendicitis remains as a differential diagnosis in older patients with abdominal pain. The Alvarado scale may assist to guide the diagnosis and treatment of this entity. The operative characteristics of the scale are little known in this population.
Method:
We conducted a systematic review of original studies published between 1986 and 2022 evaluating the diagnostic performance of the Alvarado scale in older adults with suspected acute appendicitis. The review was conducted according to the PRISMA statement. The evaluation of the methodological quality of the studies was performed according to the ROBINS-I criteria.
Results:
Four original studies of retrospective design including 480 patients were identified. The heterogeneity and poor methodological quality limited an aggregate statistical analysis (meta-analysis). The value of the ROC curve of the scale varies between 0.799 and 0.969. From the available studies, the value of the ROC curve is lower in comparison to the RIPASA scale and comparable to the Lintula scale.
Conclusions:
The evidence on the diagnostic performance of the Alvarado scale in older adults is limited. The poor methodological quality of the available studies calls for a prudent use of this tool in this population. Our findings offer opportunities for future research.
Case examples of difficult to make diagnoses in the determination of an etiology of chronic abdominal pain are reviewed. These include acalculous cholecystitis, median arcuate ligament compression syndrome, disorders of gut-brain interaction, narcotic bowel syndrome, microscopic colitis, chronic mesenteric ischemia, sphincter of Oddi dysfunction, endometriosis, chronic abdominal wall pain, epiploic appendagitis, porphyria, sclerosing mesenteritis, abdominal migraine. Conflicts about ordering CT scans in chronic abdominal pain are discussed. The peculiar circumstance of GI pathology like peptic ulcer disease and cholecystitis first presenting with complications in previously asymptomatic elderly and RA patients.
Background:
Patients with limited English proficiency (LEP) are at risk for communication barriers during medical care in the United States compared with English-proficient (EP) patients. It is unknown how EP affects the utilization of advanced diagnostic imaging (ADI) in the emergency department (ED).
Objective:
The aim of this study was to compare the acquisition and findings of ADI in EP and LEP patients with abdominal symptoms.
Methods:
We conducted a retrospective analysis of adult ED patients from January 2015 to January 2016. Patients were divided into EP and LEP cohorts. Logistic regression models incorporated language proficiency, interpretation method, and demographic characteristics. We determined crude and adjusted odds ratios (ORs) for the acquisition of ADI, defined as either computed tomography or ultrasound, and the proportion with actionable findings.
Results:
In 3324 encounters (2134 EP; 1190 LEP), LEP patients were older (46.3 years vs. 43.8 years), more likely to be female (66.7% vs. 51.5%), and preferred Spanish (91.4%). ADI was obtained in 43.5% of EP and 48.1% of LEP. Adjusting for age, sex, and interpretation method, the OR was 1.09 (95% CI 0.90-1.32). There were no significant associations between interpretation type and acquisition of ADI. The proportion with actionable findings were similar in EP and LEP cohorts (29.6% vs. 26.7%).
Conclusions:
Accounting for demographic differences, ADI acquisition was similar for ED patients with and without LEP. Further research is needed to determine optimal interpretation modalities in this setting to prevent unnecessary imaging.
Importance:
A surgical consultation is a critical first step in the care of patients with emergency general surgery conditions. It is unknown if Black Medicare patients and White Medicare patients receive surgical consultations at similar rates when they are admitted from the emergency department.
Objective:
To determine whether Black Medicare patients have similar rates of surgical consultations when compared with White Medicare patients after being admitted from the emergency department with an emergency general surgery condition.
Design, setting, and participants:
This was a retrospective cohort study that took place at US hospitals with an emergency department and used a computational generalization of inverse propensity score weight to create patient populations with similar covariate distributions. Participants were Medicare patients age 65.5 years or older admitted from the emergency department for an emergency general surgery condition between July 1, 2015, and June 30, 2018. The analysis was performed during February 2022. Patients were classified into 1 of 5 emergency general surgery condition categories based on principal diagnosis codes: colorectal, general abdominal, hepatopancreatobiliary, intestinal obstruction, and upper gastrointestinal.
Exposures:
Black vs White race.
Main outcomes and measures:
Receipt of a surgical consultation after admission from the emergency department with an emergency general surgery condition.
Results:
A total of 1 686 940 patients were included in the study. Of those included, 214 788 patients were Black (12.7%) and 1 472 152 patients were White (87.3%). After standardizing for medical and diagnostic imaging covariates, Black patients had 14% lower odds of receiving a surgical consultation (odds ratio [OR], 0.86; 95% CI, 0.85-0.87) with a risk difference of -3.17 (95% CI, -3.41 to -2.92). After standardizing for socioeconomic covariates, Black patients remained at an 11% lower odds of receiving a surgical consultation compared with similar White patients (OR, 0.89; 95% CI, 0.88-0.90) with a risk difference of -2.49 (95% CI, -2.75 to -2.23). Additionally, when restricting the analysis to Black patients and White patients who were treated in the same hospitals, Black patients had 8% lower odds of receiving a surgical consultation when compared with White patients (OR, 0.92; 95% CI, 0.90-0.93) with a risk difference of -1.82 (95% CI, -2.18 to -1.46).
Conclusions and relevance:
In this study, Black Medicare patients had lower odds of receiving a surgical consultation after being admitted from the emergency department with an emergency general surgery condition when compared with similar White Medicare patients. These disparities in consultation rates cannot be fully attributed to medical comorbidities, insurance status, socioeconomic factors, or individual hospital-level effects.
Chronic pain conditions are among the most common complaints seen in the emergency department (ED). Exacerbations of these conditions are often approached as one would an acute painful condition, with liberal use of imaging, labs, and analgesics. This patient population is often prescribed short courses of opioids without a definite explanation for their painful episodes and often leave the ED dissatisfied with their experience. We describe a patient with a history of chronic abdominal pain who presented to the ED with an exacerbation of his pain. Upon further review of his previous records, we noted that this patient experienced many similar events, resulting in 46 imaging studies over the past year. At this point, the patient was given the Central Sensitization Inventory, and his score demonstrated severe underlying central sensitization. The patient was counseled about his condition and provided with appropriate follow-up care.
This second Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE‐2) from the Society for Academic Emergency Medicine is on the topic “low‐risk, recurrent abdominal pain in the emergency department.” The multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding four priority questions for adult emergency department patients with low‐risk, recurrent, undifferentiated abdominal pain. The intended population includes adults with multiple similar presentations of abdominal signs and symptoms recurring over a period of months or years. The panel reached the following recommendations: (1) if a prior negative computed tomography of the abdomen and pelvis (CTAP) has been performed within 12 months, there is insufficient evidence to accurately identify populations in whom repeat CTAP imaging can be safely avoided or routinely recommended; (2) if CTAP with IV contrast is negative, we suggest against ultrasound unless there is concern for pelvic or biliary pathology; (3) we suggest that screening for depression and/or anxiety may be performed during the ED evaluation; and (4) we suggest an opioid‐minimizing strategy for pain control.
EXECUTIVE SUMMARY
The GRACE‐2 writing group developed clinically relevant questions to address the care of adult patients with low‐risk, recurrent, previously undifferentiated abdominal pain in the emergency department (ED). Four patient‐intervention‐comparison‐outcome‐time (PICOT) questions were developed by consensus of the writing group, who performed a systematic review of the literature and then synthesized direct and indirect evidence to formulate recommendations, following GRADE methodology. The writing group found that despite the commonality and relevance of these questions in emergency care, the quantity and quality of evidence were very limited, and even fundamental definitions of the population and outcomes of interest are lacking. Future research opportunities include developing precise and clinically relevant definitions of low‐risk, recurrent, undifferentiated abdominal pain and determining the scope of the existing populations in terms of annual national ED visits for this complaint, costs of care, and patient and provider preferences.
Objective
To examine the trends in CT utilization in the emergency department (ED) for different racial and ethnic groups, factors that may affect utilization, and the effects of increased insurance coverage since passage of the Affordable Care Act in 2010.Materials and methodsData from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for the years 2009–2018 were used for the analysis. The NHAMCS is a cross-sectional survey which has random and systematical samples of more than 200,000 visits to over 250 hospital EDs in the USA. Patient demographic characteristics, source of payment/insurance, clinical presentation, and disposition from the ED were recorded. Descriptive statistics and multivariate logistic regression were performed.ResultsBetween 2009 and 2018, the rate of uninsured patients in the ED decreased from 18.1% to as low as 9.9%, but this was not associated with a decrease in the disparity in CT utilization between non-Hispanic Black and non-Hispanic White patients. CT use rate increased 38% over the study period. Factors strongly associated with CT utilization include age, source of payment, triage category, disposition from the ED, and residence. After controlling for these factors, non-Hispanic White patients were 21% more likely to undergo CT than non-Hispanic Black patients, though no disparity was seen for Hispanic or Asian/other groups.Conclusion
Despite increased insurance coverage over the sample period, racial disparities between non-Hispanic Black and non-Hispanic White patients persist in CT utilization, though no disparity was seen for Hispanic or Asian/other patients. The source of this disparity remains unclear and is likely multifactorial.
Objective:
To compare the use of medical imaging (x-ray [XR], CT, ultrasound, and MRI) in the emergency department (ED) for adult patients of different racial and ethnic groups in the United States from 2005 to 2014.
Methods:
We performed a multilevel stratified regression analysis of the National Hospital Ambulatory Medical Care Survey ED Subfile, a nationally representative database of hospital-based ED visits. We examined race (white, black, Asian, other) and ethnicity (Hispanic versus non-Hispanic) as the primary exposures for the outcomes of ED medical imaging use (XR, CT, ultrasound, MRI, and any imaging). We controlled for other potential patient-level and facility-level determinants of ED imaging use.
Results:
Approximately half (48.8%) of the 225,037 adult patient ED visits underwent imaging; 36.1% underwent XR, 16.4% CT, 4.1% ultrasound, and 0.8% MRI. White patients received imaging during 51.3% of their encounters, black patients received imaging during 43.6% of their encounters, Asians received imaging during 50.8% of their encounters, and other races received imaging during 46% of their encounters. As compared with white patients, black patients had decreased adjusted odds of receiving imaging in the ED (odds ratio [OR] = 0.86, 95% confidence interval [CI]: 0.84-0.89). Comparatively, black patients had a lower odds of CT scan (OR = 0.80, 95% CI: 0.77-0.83) or MRI (OR = 0.74, 95% CI: 0.65-0.85). Hispanic patients and Asian patients had a higher odds of receiving ultrasound (OR = 1.36, 95% CI: 1.27-1.44 and OR = 1.25, 95% CI: 1.10-1.42), respectively.
Implications:
We observed significant racial and ethnic differences in medical imaging use in the ED even after controlling for patient- and facility-level factors.
To assess patterns of use of abdominal imaging in the emergency department (ED) from 1990 to 2009.
We retrospectively reviewed data on adult ED patients treated between 1990 and 2009 at our university-affiliated quaternary care institution. Examinations were coded by abdominal imaging modality: x-ray, sonography, CT, or MRI. Proportional costs for each imaging modality were evaluated using relative value units (RVUs). Chi-square tests were used to assess for significant trends.
The intensity of abdominal imaging per 1,000 ED visits increased 19.3% from 1990-2009 (p = 0.0050). The number of abdominal CT scans per 1,000 ED visits increased 17.5-fold (p < 0.0001). Similarly, the number of abdominal MRIs per 1,000 ED visits increased from 0 to 1.0 (p < 0.0001), and the number of abdominal sonographs per 1,000 ED visits increased 51.6% (p = 0.0198). However, the number of x-ray examinations per 1,000 ED visits decreased 81.6% (p < 0.0001). Abdominal imaging RVUs per 1,000 ED visits increased 2.7-fold (p < 0.0001), due primarily to CT imaging, which accounted for 14% of RVUs in 1990 and 76% of RVUs in 2009.
The intensity of abdominal imaging examinations per 1,000 ED visits and the number of abdominal imaging RVUs increased significantly over a 20-year period. CT replaced x-ray as the most common abdominal imaging modality for evaluation of ED patients. In light of these increasing costs as well as the increased radiation exposure of CT, clinical decision rules and computerized decision support may be needed to ensure appropriate utilization of abdominal CT in the ED.
Use of computed tomography (CT) for diagnostic evaluation has increased dramatically over the past 2 decades. Even though CT is associated with substantially higher radiation exposure than conventional radiography, typical doses are not known. We sought to estimate the radiation dose associated with common CT studies in clinical practice and quantify the potential cancer risk associated with these examinations.
We conducted a retrospective cross-sectional study describing radiation dose associated with the 11 most common types of diagnostic CT studies performed on 1119 consecutive adult patients at 4 San Francisco Bay Area institutions in California between January 1 and May 30, 2008. We estimated lifetime attributable risks of cancer by study type from these measured doses.
Radiation doses varied significantly between the different types of CT studies. The overall median effective doses ranged from 2 millisieverts (mSv) for a routine head CT scan to 31 mSv for a multiphase abdomen and pelvis CT scan. Within each type of CT study, effective dose varied significantly within and across institutions, with a mean 13-fold variation between the highest and lowest dose for each study type. The estimated number of CT scans that will lead to the development of a cancer varied widely depending on the specific type of CT examination and the patient's age and sex. An estimated 1 in 270 women who underwent CT coronary angiography at age 40 years will develop cancer from that CT scan (1 in 600 men), compared with an estimated 1 in 8100 women who had a routine head CT scan at the same age (1 in 11 080 men). For 20-year-old patients, the risks were approximately doubled, and for 60-year-old patients, they were approximately 50% lower.
Radiation doses from commonly performed diagnostic CT examinations are higher and more variable than generally quoted, highlighting the need for greater standardization across institutions.
Abdominal pain is a common cause for emergency admission. While some patients have serious abdominal pathology, a significant group of those patients have no specific cause for the pain. This study was conducted to identify those who have non-specific abdominal pain who can be either admitted short term for observation or reassured and discharged for outpatient management.
A prospective documentation of clinical and laboratory data was obtained on a consecutive cohort of 286 patients who were admitted to a surgical unit over a nine month period with symptoms of abdominal pain regarded severe enough for full assessment in the casualty department and admission to a surgical ward. The patients were followed until a definite diagnosis was made or the patient's condition and abdominal pain improved and the patient discharged. The hospital where the study took place is a small peripheral general hospital draining a population of 120,000 people in a rural area in New Zealand.
There were 286 admissions to the emergency department. Logistic regression multivariate statistical analysis showed that guarding raised white cells count, tachycardia and vomiting were the only variables associated with significant pathology.
Patients with no vomiting, no guarding, who have normal pulse rates and normal white cell counts are unlikely to have significant pathology requiring further active intervention either medical or surgical.
Annually, approximately 70 million computed tomography (CT) scans are performed in emergency department (ED) settings in the United States of America. From 1995 to 2007, there has been a 5.9-fold increase in the use of CT scans nationally. The radiation risks and high costs associated with CT scans underscore the fact that the imaging modality, although necessary, carries a myriad of long-term risks to both patients and providers. For the workup of abdominal pain, most algorithms include the use of CT scan as an early step. To understand better the use of CT scans in our ED, we performed a retrospective review of patients presenting to the ED with abdominal pain. Two main questions were addressed: 1) what were the reasons for scans and how often did the scans reveal pathology related to the presenting symptoms, 2) how often were incidental findings identified. Our results showed that among patients presenting with abdominal pain to the ED, 50 per cent of the scans were normal, about 20 per cent of the patients had findings correlating with acute abdominal pain, whereas the rest (30%) had incidental findings that may have led to further outpatient studies or long standing abdominal pain. Most patients who presented to the ED had nonspecific abdominal pain i.e. 64.4 per cent. There was a low agreement between the presenting quadrant of pain and final pathological diagnosis (9.5-33.3% concordance), with left flank pain presentation having the highest level of agreement with the final pathologic diagnosis.
Background
Increases in life expectancy has meant that a higher proportion of patients presenting to surgical assessment units are now elderly. Abdominal computed tomography (CT) can provide early and accurate diagnosis in the elderly, even in the presence of incomplete clinical and biological findings. The aim of this study was to investigate the use of early CT imaging in elderly patients presenting directly to the surgical assessment unit.
Materials and methods
All consecutive patients aged 65 years and over admitted directly to the surgical assessment unit between January 2017 and April 2017 were identified. Data were collected on demographics, laboratory investigations, radiological investigations and hospital admission. The primary outcome measure was overall length of stay.
Results
A total of 200 consecutive patients were identified and included over a six-month period. This comprised 110 women and 90 men with a median age of 78 years (range 64–98 years). A total of 83 patients underwent CT on admission to the surgical assessment unit. White cell count (WCC) and C-reactive protein (CRP) results were significantly higher in patients undergoing CT (P = 0.001). Median length of stay for patients undergoing CT was 5 days (range 1–19 days). This was significantly lower than those patients not receiving CT imaging, at 6 days (range 1–105 days; P = 0.034).
Discussion
CT should be considered as a first-line investigation when elderly patients with an acute abdomen are admitted to surgical assessment units. Early CT can accelerate hospital discharge and decrease overall length of hospital stay.
Background:
Emergency departments (ED) are sites of prevalent imaging overuse; however, determinants that drive imaging in this setting are not well-characterized. We systematically reviewed the literature to summarize the determinants of imaging overuse in the ED.
Methods:
We searched MEDLINE® and Embase® from January 1998 to March 2017. Studies were included if they were written in English, contained original data, pertained to a U.S. population, and identified a determinant associated with overuse of imaging in the ED.
Results:
Twenty relevant studies were included. Fourteen evaluated computerized tomography (CT) scanning in patents presenting to a regional ED who were then transferred to a level 1 trauma center; incomplete transfer of data and poor image quality were the most frequently described reasons for repeat scanning. Unnecessary pre-transfer scanning or repeated scanning after transfer, in multiple studies, was highest among older patients, those with higher Injury Severity Scores (ISS) and those being transferred further. Six studies explored determinants of overused imaging in the ED in varied conditions, with overuse greater in older patients and those having more comorbid diseases. Defensive imaging reportedly influenced physician behavior. Less integration of services across the health system also predisposed to overuse of imaging.
Conclusions:
The literature is heterogeneous with surprisingly few studies of determinants of imaging in minor head injury or of spine imaging. Older patient age and higher ISS were the most consistently associated with ED imaging overuse. This review highlights the need for precise definitions of overuse of imaging in the ED.
To determine the effect of abdominal computed tomographic (CT) scan results on diagnosis and disposition of patients with non-traumatic abdominal pain who were evaluated by board-certified emergency physicians (EPs).
Prospective, observational study conducted at a safety-net facility with an emergency medicine residency and 65000 annual adult visits. Patients with non-traumatic abdominal pain who underwent an abdominal CT from 3/2011 through 8/2011 were included. Decision to obtain CT was made by the EP. The computer order entry system required the EP to report the most likely diagnosis, and the management and disposition plan. After CT results, the same EP electronically again entered the most likely diagnosis and the planned management and disposition. CTs were interpreted by an attending radiologist. Descriptive statistics and χ(2) tests were used.
Six hundred twenty-nine patients were entered and 547 remained after exclusions; 298 (54%) subjects had a change in diagnosis. In 6 categories, there was a statistically significant change, with non-specific abdominal pain the most common(P < .001); followed by renal colic (P < .001), appendicitis (P < .001), diverticulitis (P < .001), small bowel obstruction (P < .029), and gynecologic process (P < .001). The most common disposition plan was "admit for observation," which was reported in 262 patients and remained in only 122 post CT (47%); 301 (54%) patients whose initial plan was admission were ultimately managed otherwise.
Abdominal CT use by board certified EPs for nontraumatic abdominal pain changed diagnosis and disposition, with more sent home in lieu of admission. Diagnostic accuracy did not appear to be related to years of clinical experience.
Copyright © 2015. Published by Elsevier Inc.
The objective was to determine emergency physician (EP) perceptions regarding 1) the extent to which they order medically unnecessary advanced diagnostic imaging, 2) factors that contribute to this behavior, and 3) proposed solutions for curbing this practice.
As part of a larger study to engage physicians in the delivery of high-value health care, two multispecialty focus groups were conducted to explore the topic of decision-making around resource utilization, after which qualitative analysis was used to generate survey questions. The survey was extensively pilot-tested and refined for emergency medicine (EM) to focus on advanced diagnostic imaging (i.e., computed tomography [CT] or magnetic resonance imaging [MRI]). The survey was then administered to a national, purposive sample of EPs and EM trainees. Simple descriptive statistics to summarize physician responses are presented.
In this study, 478 EPs were approached, of whom 435 (91%) completed the survey; 68% of respondents were board-certified, and roughly half worked in academic emergency departments (EDs). Over 85% of respondents believe too many diagnostic tests are ordered in their own EDs, and 97% said at least some (mean = 22%) of the advanced imaging studies they personally order are medically unnecessary. The main perceived contributors were fear of missing a low-probability diagnosis and fear of litigation. Solutions most commonly felt to be "extremely" or "very" helpful for reducing unnecessary imaging included malpractice reform (79%), increased patient involvement through education (70%) and shared decision-making (56%), feedback to physicians on test-ordering metrics (55%), and improved education of physicians on diagnostic testing (50%).
Overordering of advanced imaging may be a systemic problem, as many EPs believe a substantial proportion of such studies, including some they personally order, are medically unnecessary. Respondents cited multiple complex factors with several potential high-yield solutions that must be addressed simultaneously to curb overimaging.
© 2015 by the Society for Academic Emergency Medicine.
ContextThe literature on disparities in health care has examined the contrast between white patients receiving needed care, compared with racial/ethnic minority patients not receiving needed care. Racial/ethnic differences in the overuse of care, that is, unneeded care that does not improve patients’ outcomes, have received less attention. We systematically reviewed the literature regarding race/ethnicity and the overuse of care.Methods
We searched the Medline database for US studies that included at least 2 racial/ethnic groups and that examined the association between race/ethnicity and the overuse of procedures, diagnostic (care) or therapeutic care. In a recent review, we identified studies of overuse by race/ethnicity, and we also examined reference lists of retrieved articles. We then abstracted and evaluated this information, including the population studied, data source, sample size and assembly, type of care, guideline or appropriateness standard, controls for clinical confounding and financing of care, and findings.FindingsWe identified 59 unique studies, of which 11 had a low risk of methodological bias. Studies with multiple outcomes were counted more than once; collectively they assessed 74 different outcomes. Thirty-two studies, 6 with low risks of bias (LRoB), provided evidence that whites received more inappropriate or nonrecommended care than racial/ethnic minorities did. Nine studies (2 LRoB) found evidence of more overuse of care by minorities than by whites. Thirty-three studies (6 LRoB) found no relationship between race/ethnicity and overuse.Conclusions
Although the overuse of care is not invariably associated with race/ethnicity, when it was, a substantial proportion of studies found greater overuse of care among white patients. Clinicians and researchers should try to understand how and why race/ethnicity might be associated with overuse and to intervene to reduce it.
Objectives:
Although computerized decision support for imaging is often recommended for optimizing computed tomography (CT) use, no studies have evaluated emergency physicians' (EPs') preferences regarding computerized decision support in the emergency department (ED). In this needs assessment, the authors sought to determine if EPs view overutilization as a problem, if they want decision support, and if so, the kinds of support they prefer.
Methods:
A 42-item, Web-based survey of EPs was developed and used to measure EPs' attitudes, preferences, and knowledge. Key contacts at local EDs sent letters describing the study to their physicians. Exploratory principal components analysis (PCA) was used to determine the underlying factor structure of multi-item scales, Cronbach's alpha was used to measure internal consistency of items on a scale, Spearman correlations were used to describe bivariate associations, and multivariable linear regression analysis was used to identify variables independently associated with physician interest in decision support.
Results:
Of 235 surveys sent, 155 (66%) EPs responded. Five factors emerged from the PCA. EPs felt that: 1) CT overutilization is a problem in the ED (α = 0.75); 2) a patient's cumulative CT study count affects decisions of whether and what type of imaging study to order only some of the time (α = 0.75); 3) knowledge that a patient has had prior CT imaging for the same indication makes EPs less likely to order a CT (α = 0.42); 4) concerns about malpractice, patient satisfaction, or insistence on CTs affect CT ordering decisions (α = 0.62); and 5) EPs want decision support before ordering CTs (α = 0.85). Performance on knowledge questions was poor, with only 18% to 39% correctly responding to each of the three multiple-choice items about effective radiation doses of chest radiograph and single-pass abdominopelvic CT, as well as estimated increased risk of cancer from a 10-mSv exposure. Although EPs wanted information on patients' cumulative exposures, they feel inadequately familiar with this information to make use of it clinically. If provided with patients' cumulative radiation exposures from CT, 87% of EPs said that they would use this information to discuss imaging options with their patients. In the multiple regression model, which included all variables associated with interest in decision support at p < 0.10 in bivariate tests, items independently associated with EPs' greater interest in all types of decision support proposed included lower total knowledge scores, greater frequency that cumulative CT study count affects EP's decision to order CTs, and greater agreement that overutilization of CT is a problem and that awareness of multiple prior CTs for a given indication affects CT ordering decisions.
Conclusions:
Emergency physicians view overutilization of CT scans as a problem with potential for improvement in the ED and would like to have more information to discuss risks with their patients. EPs are interested in all types of imaging decision support proposed to help optimize imaging ordering in the ED and to reduce radiation to their patients. Findings reveal several opportunities that could potentially affect CT utilization.
The role of computed tomography (CT) in acute illnesses has increased substantially in recent years; however, little is known about how CT use in the emergency department (ED) has changed over time.
A retrospective study was performed with the 1996 to 2007 National Hospital Ambulatory Medical Care Survey, a large nationwide survey of ED services. We assessed changes during this period in CT use during an ED visit, CT use for specific ED presenting complaints, and disposition after CT use. Main outcomes were presented as adjusted risk ratios (RRs).
Data from 368,680 patient visits during the 12-year period yielded results for an estimated 1.29 billion weighted ED encounters, among which an estimated 97.1 million (7.5%) patients received at least one CT. Overall, CT use during ED visits increased 330%, from 3.2% of encounters (95% confidence interval [CI] 2.9% to 3.6%) in 1996 to 13.9% (95% CI 12.8% to 14.9%) in 2007. Among the 20 most common complaints presenting to the ED, there was universal increase in CT use. Rates of growth were highest for abdominal pain (adjusted RR comparing 2007 to 1996=9.97; 95% CI 7.47 to 12.02), flank pain (adjusted RR 9.24; 95% CI 6.22 to 11.51), chest pain (adjusted RR 5.54; 95% CI 3.75 to 7.53), and shortness of breath (adjusted RR 5.28; 95% CI 2.76 to 8.34). In multivariable modeling, the likelihood of admission or transfer after a CT scan decreased over the years but has leveled off more recently (adjusted RR comparing admission or transfer after CT in 2007 to 1996=0.42; 95% CI 0.32 to 0.55).
CT use in the ED has increased significantly in recent years across a broad range of presenting complaints. The increase has been associated with a decline in admissions or transfers after CT use, although this effect has stabilized more recently.
The objective of our study was to prospectively determine how CT affects physicians' diagnostic certainty and management decisions in the setting of patients with nontraumatic abdominal complaints presenting to the emergency department.
We included 584 patients presenting with nontraumatic abdominal complaints to the emergency department from November 2006 through February 2008. Emergency department clinicians were prospectively surveyed both before abdominal CT (pre-CT) and after abdominal CT (post-CT) to determine the leading diagnosis, the diagnostic certainty, and the management decisions. Changes were assessed by Fisher's exact test and the log likelihood ratio.
The most common diagnoses were renal colic (119/584, 20.4%) and intestinal obstruction (80/584, 13.7%). CT altered the leading diagnosis in 49% of the patients (284/584, p < 0.00001) and increased mean physician diagnostic certainty from 70.5% (pre-CT) to 92.2% (post-CT) (p < 0.001; log likelihood ratio, 2.48). The management plan was changed by CT in 42% (244/583) (p < 0.0001). Physicians planned to admit 75.3% of the patients (440/584) to the hospital before CT; that plan was changed to hospital discharge with follow-up in 24.1% of patients (106/440) after CT. Surgery was planned for 79 patients before CT, whereas hospital discharge was planned for 25.3% of these patients (20/79) after CT.
In the management of patients presenting to the emergency department with nontraumatic abdominal complaints, CT changes the leading diagnosis, increases diagnostic certainty, and changes potential patient management decisions.
The aim of this study was to retrospectively analyze a large group of CT and MRI examinations for appropriateness using evidence-based guidelines.
The authors reviewed medical records from 459 elective outpatient CT and MR examinations from primary care physicians. Evidence-based appropriateness criteria from a radiology benefit management company were used to determine if the examination would have met criteria for approval. Submitted clinical history at the time of interpretation and clinic notes and laboratory results preceding the date of the imaging study were examined to simulate a real-time consultation with the referring provider. The radiology reports and subsequent clinic visits were analyzed for outcomes.
Of the 459 examinations reviewed, 284 (62%) were CT and 175 (38%) were MRI. Three hundred forty-one (74%) were considered appropriate, and 118 (26%) were not considered appropriate. Examples of inappropriate examinations included brain CT for chronic headache, lumbar spine MR for acute back pain, knee or shoulder MRI in patients with osteoarthritis, and CT for hematuria during a urinary tract infection. Fifty-eight percent of the appropriate studies had positive results and affected subsequent management, whereas only thirteen percent [corrected] of inappropriate studies had positive results and affected management.
A high percentage of examinations not meeting appropriateness criteria and subsequently yielding negative results suggests a need for tools to help primary care physicians improve the quality of their imaging decision requests. In the current environment, which stresses cost containment and comparative effectiveness, traditional radiology benefit management tools are being challenged by clinical decision support, with an emphasis on provider education coupled with electronic order entry systems.
The usefulness of the rebound tenderness test in indicating peritonitis was prospectively assessed in 142 unselected patients admitted as emergencies with abdominal pain and tenderness. It was found to be of no predictive value.
Two series from greater Stockholm consisting of 726 (1960 to 1968) and 1,000 (1977 to 1978) patients over age 70 years with acute abdominal complaints are presented. Almost two thirds were women. Acute cholecystitis dominated both series, but its incidence decreased from 40.8 to 26 percent in the later series. The incidence of malignant disease increased from 3 to 13.2 percent. About one third of the patients were operated on; 50 percent had postoperative complications. Some frequently occurring aberrations of the usual symptoms and signs in acute appendicitis, ileus, and perforated gastric duodenal ulcer are discussed. The overall therapeutic results improved, as judged by postoperative mortality (series I, 23.1; series II, 16 percent) and mortality associated with individual diseases (except for acute pancreatitis). However, total mortality only decreased from 14 to 11.3 percent due to the large number of malignant diseases in series II, which were associated with a mortality of 37.9 percent. In series II the median duration of stay was 10.5 days and 75 percent of the patients were discharged home.
The purpose of this study is to document the impact of CT performed in the emergency department of patients presenting with nontraumatic acute abdominal pain.
Fifty-seven patients were enrolled in this prospective study. Using a computer order entry system, emergency department physicians were required to report their most likely diagnosis, level of certainty, and management plan for their patients before ordering abdominal CT. After CT was performed, each physician was required to provide again his or her diagnosis, level of diagnostic certainty, and treatment plan. The outcome of each patient was evaluated by either surgery, other imaging studies, or clinical follow-up.
After the abdominal CT, physicians' mean level of certainty in their diagnoses increased by 1.5 points (on a five-point scale; p < 0.0001). Patient management was changed in 33 (60.0%) of 55 patients. Planned treatment before CT was admission in 42 patients. Actual admissions after CT totaled 32 patients (excluding the two patients in whom preimaging information was not recorded). Thus, the net effect of abdominal CT scanning was to avert 10 (23.8%) of 42 hospital admissions.
CT performed in the emergency department increases the physician's level of certainty, reduces hospital admission rates by 23.8%, and leads to more timely surgical intervention.
Computed tomography (CT) is widely used in the initial evaluation of blunt trauma patients and is associated with a high rate of negative imaging. A described benefit of negative imaging is prompt discharge. This study examined a single level 1 trauma center to determine whether adult blunt trauma patients are discharged from the emergency department (ED) after negative CT of the abdomen and pelvis (CT AP).
The authors retrospectively created a data set of adult blunt trauma patients who received CT AP in the ED from August to November 2003. Statistical analysis of admission rates on the basis of positivity or negativity on CT AP was performed to determine if the test influenced admission rates. Additional subgroup analysis was made between the patients admitted with negative CT AP and those who were discharged from the ED.
Two thirds (316/469) had negative CT AP. Whereas 80.4% of the patients (254/316) with negative CT AP were admitted, 98.0% (148/151) with positive CT AP were admitted, a statistically significant difference in admission rate (P < .0001). The vast majority (208/254, 81.9%) of patients with negative CT AP were admitted for extra-abdominal injuries. There was no statistical difference in the characteristics of a subgroup of 45 patients who were admitted without any documented injuries from the group discharged from the ED in terms of age, gender, comorbidity, Glasgow Coma Scale score, or intoxication.
Under current practice, negative CT AP after blunt trauma results in a statistically significant decrease in admissions.
Acute abdominal pain is a common diagnostic problem. This study aimed to evaluate the routinely use of contrast enhanced computed tomographic (CT) scanning early in the diagnostic process.
A retrospective review of 2,222 patients with acute abdominal pain who underwent contrast enhanced CT scanning within 24 h after admission. The diagnoses obtained were compared with the final diagnoses after 1 month.
After CT scanning the following diagnoses were suggested as the primary cause of the abdominal pain: nonspecific abdominal pain 984 (44.3%), appendicitis 354 (15.9%), bowel obstruction 190 (8.6%), diverticulitis 182 (8.2%), gastrointestinal perforation 52 (2.3%), gallstone disease 64 (2.9%), pancreatitis 72 (3.2%), inflammatory bowel disease 13 (0.6%), intra-abdominal malignancy 34 (1.5%), vascular disease (including 1 completely cured patient with paradoxical embolization in the superior mesenteric artery) 33 (1.5%), urological 131 (5.9%), gynecological 54 (2.4%), miscellaneous 31 (1.4%). In 28 cases a conclusive CT examination could not be carried out. The suggested diagnoses were correct in 2,151 cases (96.8%). In 16 cases (0.7%) an incorrect diagnosis was reported, leading to 7 unnecessary laparotomies. False negative reports were obtained in 27 cases (1.2%). After CT examination 500 patients could be discharged immediately.
Contrast-enhanced CT scanning results in superior diagnostic precision in patients with acute abdominal pain. The present work supports the strategy to include this examination early in the routine diagnostic process.
The number of computed tomographic (CT) studies performed is increasing rapidly. Because CT scans involve much higher doses of radiation than plain films, we are seeing a marked increase in radiation exposure in the general population. Epidemiologic studies indicate that the radiation dose from even two or three CT scans results in a detectable increase in the risk of cancer, especially in children. This article summarizes the facts about this form of radiation exposure and the implications for public health.
Imperative: achieving greater value in health care
- M Smith
- R Saunders
- L Stuckhardt
nopelvic CT increases diagnostic certainty and guides management decisions: a prospective investigation of 584 patients in a large academic medical center
- M Smith
- R Saunders
- L Stuckhardt
Smith M, Saunders R, Stuckhardt L, et al. Imperative: achieving
greater value in health care. In: Best Care at Lower Cost: The Path to
Continuously Learning Health Care in America. Washington, DC:
National Academies Press, 2013. Available at: https://www.ncbi.nlm.
nih.gov/books/NBK207222/. Accessed June 8, 2019.
3. Massachusetts Medical Society Home [Internet]. Available
at: http://www.massmed.org/Default.aspx. Accessed June 8, 2019.
4. Abujudeh HH, Kaewlai R, McMahon PM, et al. Abdominopelvic CT increases diagnostic certainty and guides management
decisions: a prospective investigation of 584 patients in a large
academic medical center. AJR Am J Roentgenol 2011;196:238-43.
Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved decision support
- A Bhatt
- X Yang
- N Karnik
Bhatt A, Yang X, Karnik N, et al. Use of computerized
tomography in abdominal pain [Internet], 2018. Available at:
https://www.ingentaconnect.com/content/sesc/tas/2018/00000084/
00000006/art00071. Accessed June 8, 2019.
16. Strömberg C, Johansson G, Adolfsson A. Acute abdominal
pain: diagnostic impact of immediate CT scanning. World J Surg
2007;31:2347-54; discussion 2355-8.
17. Heilbrun ME, Chew FS, Tansavatdi KR, et al. The role of
negative CT of the abdomen and pelvis in the decision to admit
adults from the emergency department after blunt trauma. J Am
Coll Radiol 2005;2:889-95.
18. Lehnert BE, Bree RL. Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved
decision support? J Am Coll Radiol 2010;7:192-7.
National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Population Health and Public Health Practice, et al. The state of health disparities in the United States
- S M Abbas
- T Smithers
- E Truter
- J D Schrager
- R E Patzer
- J J Kim
Abbas SM, Smithers T, Truter E. What clinical and laboratory parameters determine significant intra abdominal pathology
for patients assessed in hospital with acute abdominal pain? World
J Emerg Surg 2007;2:26.
20. National Academies of Sciences, Engineering, and Medicine,
Health and Medicine Division, Board on Population Health and Public
Health Practice, et al. The state of health disparities in the United States.
In: Communities in Action: Pathways to Health Equity. Washington,
DC: National Academies Press, 2017. Available at: https://www.
ncbi.nlm.nih.gov/books/NBK425844/. Accessed August 27, 2019.
21. Schrager JD, Patzer RE, Kim JJ, et al. Racial and ethnic
differences in diagnostic imaging utilization during adult emergency department visits in the United States, 2005 to 2014. J Am
Coll Radiol 2019;16:1036-45.
Use of computerized tomography in abdominal pain
- Bhatta
- Yangx
- Karnikn