Abstract
IntroductionThis study investigated whether a 9.6% decrease in the use of head computed tomography (HCT) for patients presenting to the emergency department (ED) with a chief complaint of headache was followed by an increase in proportions of death or missed intracranial diagnosis during the 22.5-month period following each index ED visit.MethodsWe reviewed the electronic medical records of all patients sampled during a quality improvement effort in which the aforementioned decrease in HCT use had been observed. We reviewed notes from the ED, neurology, neurosurgery, and primary care services, as well as all brain imaging results to determine if death occurred or if an intracranial condition was discovered in the 22.5 months after each index ED visit. An independent, blinded reviewer reviewed each case where an intracranial condition was diagnosed after ED discharge to determine whether the condition was reasonably likely to have been related to the index ED visit’s presentation, thereby representing a missed diagnosis.ResultsOf the 582 separate index ED visits sampled, we observed a total of nine deaths and 10 missed intracranial diagnoses. There was no difference in the proportion of death (p = 0.337) or missed intracranial diagnosis (p = 0.312) observed after a 9.6% reduction in HCT use. Among patients who subsequently had visits for headache or brain imaging, we found that these patients were significantly more likely to have not had a HCT done during the index ED visit (59.2% vs. 49.6% (p = 0.031) and 37.1% vs. 26% (p = 0.006), respectively).ConclusionOur study adds to the compelling evidence that there is opportunity to safely decrease CT imaging for ED patients. To determine the cost effectiveness of such reductions further research is needed to measure what patients and their healthcare providers do after discharge from the ED when unnecessary testing is withheld.
Highlights
This study investigated whether a 9.6% decrease in the use of head computed tomography (HCT) for patients presenting to the emergency department (ED) with a chief complaint of headache was followed by an increase in proportions of death or missed intracranial diagnosis during the 22.5-month period following each index ED visit
There was no difference in the proportion of death (p = 0.337) or missed intracranial diagnosis (p = 0.312) observed after a 9.6% reduction in HCT use
Among patients who subsequently had visits for headache or brain imaging, we found that these patients were significantly more likely to have not had a HCT done during the index ED visit (59.2% vs. 49.6% (p = 0.031) and 37.1% vs. 26% (p = 0.006), respectively)
Summary
This study investigated whether a 9.6% decrease in the use of head computed tomography (HCT) for patients presenting to the emergency department (ED) with a chief complaint of headache was followed by an increase in proportions of death or missed intracranial diagnosis during the 22.5-month period following each index ED visit. Headache is a common complaint in the emergency department (ED).[1] Use of imaging has increased since computed tomography (CT) was introduced in 1972.2-4 In 2010, CTs were performed in 13.9% of U.S ED visits, and. 48% of these were of the head (HCT).[5] While this rise has been associated with a decline in rates of admission and transfer,[6] multiple sources have suggested that HCT use in the ED could be decreased through quality improvement efforts.[7,8,9,10]. Reduced CT Use in the ED Evaluation of Headache evaluation of headache varies widely, and 97% of EPs surveyed felt that at least some of the imaging studies ordered in EDs were medically unnecessary.[9,15] The American College of Emergency Physiciansreleased its Choosing Wisely Campaign in 2013, which included avoiding HCTs in patients with minor head injury who are at low risk based on validated decision rules.[11,12] During the 2015 Academy of Emergency Medicine Consensus Conference on diagnostic imaging in the emergency department, participants suggested that allowing providers to influence metrics could produce better quality metrics; they suggested that knowledge translation for the optimization of diagnostic imaging use should be a core area warranting further research.[13,17]
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