Overuse Of Computed Tomography Research Articles

Scandinavian Neurotrauma Guidelines: Frequency of intracranial hemorrhage in patients over 65 years old and on anti-platelet medication

PurposeIn 2013, the Scandinavian Neurotrauma Committee, produced an evidence-based guideline for the use of Computed Tomography (CT) in patients presenting following recent (<24 h) head injury (HI). A head CT scan is recommended for medium-risk patients with a Glasgow Coma Scale (GCS) score of 14–15, who are > 65 years old and on anti-platelet medication. The aim of this study was to determine the prevalence of intracranial hemorrhage (ICH) on head CT scans in this population, and to test for associations between ICH and baseline characteristics, symptoms and objective clinical findings. MethodsThis register-based retrospective study determined the prevalence of ICH on head CT scans performed over a 1-year period based on written CT-reports. Patient medical charts and imaging records were examined for data on symptomatology, objective findings and comorbidities. ResultsThe study population included 325 unique head CT scans with a 5.2% prevalence of ICH. Risk ratios (RR’s) signified higher risk of ICH with a GCS score of 14 compared to a GCS score of 15 (RR 5.35, 95%CI 2.14–13.47). ICH risk was lower in patients on Clopidogrel medication compared to Acetylsalicylic Acid medication (RR 0.33, 95%CI 0.12–0.93). ConclusionsThe associations between ICH and the GCS score call attention to the importance of comprehensive clinical examination of HI patients to minimize CT overuse. The implications for patients and healthcare resources in scanning patients > 65 years on anti-platelet medication should be determined by future prospective studies.

Computed Tomography Overuse in Pediatric Minor Head Trauma: Insights from a Single-Center Experience.

Minor head trauma is a common reason for emergency department visits in children, but many of these cases are not clinically significant. Despite established criteria for selecting patients who require computed tomography (CT), concerns about overuse of CT persist. This study aimed to determine the frequency of clinically important traumatic brain injury by retrospectively evaluating cranial CT scans in children categorized as very low risk for such injuries based on PECARN prediction rules. Cranial CT scans of 941 minor head trauma cases were assessed for the presence, type, and number of calvarial bone fractures. Concomitant bleeding and treatment approaches were also recorded. Among 881 patients (93.6%), cranial CT scans did not reveal any lesions apart from soft tissue edema. None of the cases had clinically important traumatic brain injury or required neurosurgical intervention. The study demonstrated that 93.6% of cranial CT scans for pediatric minor head trauma were negative, indicating a concerningly high rate of CT overuse. Although prediction rules exist, their application in clinical practice is not always optimal. Given the principle of "first, do no harm," proper patient selection is crucial to avoid unnecessary exposure to ionizing radiation.

Prevalence of Computed Tomography Overuse for Mild Head Injury in Adults.

The Canadian CT Head Rule (CCHR) is one of many established guidelines for assessing the need for computed tomography (CT) imaging in patients with minor head injuries. Adhering to such criteria would promote the appropriate use of CT imaging, lower healthcare expenses, and prevent harmful radiation exposure. There is no current literature assessing the overuse of CT imaging for minor head injuries in the Kingdom of Bahrain. This study aims to evaluate CT overuse in adult patients with minor head trauma. Methods: The study was conducted at the Bahrain Defense Force Hospital over 12 months from January to December 2021. All adult patients (>14 years) who sustained a minor head injury and were referred to the emergency department for CT brain imaging were included in the study. Patients presenting for other reasons or suffering from moderate to severe head injuries were excluded. CT reports were retrieved for analysis. The CCHR was used as a reference. Results: A total of 486 CT scans were performed. Loss of consciousness was the most commonsymptom on presentation (n = 74 cases). Only 12.1% of CT scans reported positive findings. The prevalence of CT overuse was highest in patients aged 21-30 years. Patients presenting with loss of consciousness showed a high overuse of CT imaging, accounting for 20.3% of all cases. Only 77.4% of cases met the CCHR criteria and 22.6% were defined as overuse, with 95% confidence interval (0.189, 0.266). Conclusion: When referring to the CCHR, CT imaging for a minor head injury in adults was overused in 22.6% of cases. Further research will be required to reveal the underlying reasons for these findings along with interventions to reduce future overuse.

Validation of Prediction Rules for Computed Tomography Use in Children With Blunt Abdominal or Blunt Head Trauma: Protocol for a Prospective Multicenter Observational Cohort Study.

Traumatic brain injuries (TBIs) and intra-abdominal injuries (IAIs) are 2 leading causes of traumatic death and disability in children. To avoid missed or delayed diagnoses leading to increased morbidity, computed tomography (CT) is used liberally. However, the overuse of CT leads to inefficient care and radiation-induced malignancies. Therefore, to maximize precision and minimize the overuse of CT, the Pediatric Emergency Care Applied Research Network (PECARN) previously derived clinical prediction rules for identifying children at high risk and very low risk for IAIs undergoing acute intervention and clinically important TBIs after blunt trauma in large cohorts of children who are injured. This study aimed to validate the IAI and age-based TBI clinical prediction rules for identifying children at high risk and very low risk for IAIs undergoing acute intervention and clinically important TBIs after blunt trauma. This was a prospective 6-center observational study of children aged <18 years with blunt torso or head trauma. Consistent with the original derivation studies, enrolled children underwent routine history and physical examinations, and the treating clinicians completed case report forms prior to knowledge of CT results (if performed). Medical records were reviewed to determine clinical courses and outcomes for all patients, and for those who were discharged from the emergency department, a follow-up survey via a telephone call or SMS text message was performed to identify any patients with missed IAIs or TBIs. The primary outcomes were IAI undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion, or intravenous fluid for ≥2 days for pancreatic or gastrointestinal injuries) and clinically important TBI (death from TBI, neurosurgical procedure, intubation for >24 hours for TBI, or hospital admission of ≥2 nights due to a TBI on CT). Prediction rule accuracy was assessed by measuring rule classification performance, using standard point and 95% CI estimates of the operational characteristics of each prediction rule (sensitivity, specificity, positive and negative predictive values, and diagnostic likelihood ratios). The project was funded in 2016, and enrollment was completed on September 1, 2021. Data analyses are expected to be completed by December 2022, and the primary study results are expected to be submitted for publication in 2023. This study will attempt to validate previously derived clinical prediction rules to accurately identify children at high and very low risk for clinically important IAIs and TBIs. Assuming successful validation, widespread implementation is then indicated, which will optimize the care of children who are injured by better aligning CT use with need. RR1-10.2196/43027.

Nonindicated Brain Computed Tomography Scans for Children: Adaptation of an American Measurement Tool and Contrast of Current Practice in an Australian Hospital.

Clinical guidelines state brain computed tomography (CT) for atraumatic headache or first generalized afebrile, atraumatic seizure as nonindicated in neurologically normal children. We aimed to adapt 2 rigorously validated United States-based measures that examine overuse of CT in children with these conditions, and to determine whether these measures can be used in an Australian setting to determine rates of CT scanning in current practice. Within an Australian tertiary pediatric hospital, we successfully adapted the measures from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding system of the United States measures to the International Classification of Diseases, Tenth Revision, Australian Modification (ICD-10-AM) coding system used in Australia. We conducted a retrospective audit of electronic medical record data from April 1, 2017, to March 31, 2018. Eligible patients were children aged 4 to 17 years who attended one of the hospital outpatient clinics and/or emergency department and/or were admitted to an inpatient ward. The conditions of interest were (1) atraumatic headache and (2) first generalized afebrile, atraumatic seizure. The measure for afebrile seizure was found to have low accuracy and low feasibility in this setting and was not tested further. The adapted measure for atraumatic headache was highly accurate in determining the encounters of interest; however, manual chart review was required to identify nonindicated brain CTs. Using this measure, 601 encounters for atraumatic headache were identified, of which 98 (16.3%) received at least 1 brain CT. We found that 14.1% of these scans were nonindicated, meaning 2% all atraumatic headache encounters received a nonindicated scan; lower than rates reported in international literature. Using the tool developed in this study, rigorous measurement of the overuse of CT scans in other settings may determine the reasons for the lower rates observed in this study; inform future interventions to minimize overuse; and provide safer, higher quality care to children.

Implementation of the Choosing Wisely Program in the General Surgery Residency

The practice of unnecessary conduct and waste in Health is an important topic, not often addressed during undergraduate training. Medical education has a fundamental role in student and doctors' training concerning cost-conscious attitudes for good health care. The aim of this study was to describe and assess the implementation of the Choosing Wisely campaign within a General Surgery residency program. This was an interventional study involving residency advisors and specialty residents. Recommendations based on three procedures frequently used in clinical practice, with no benefits and involving unnecessary risks for patients were identified by residency advisors with the use of the Delphi method and were grouped by frequency and by nature according to the Choosing Wisely layout. Educational actions such as workshops and banner advertising in addition to training activities regarding cost-conscious healthcare were carried out. This subject was also included in the theoretical evaluation of the residency program. The leading five recommendations were related to (i) computed tomography overuse (versus ultrasound imaging) in patients with suspected acute appendicitis, (ii) multithreaded computed tomography overuse in patients with low-risk trauma, (iii) longer than recommended antibiotic prophylaxis in surgical patients, (iv) longer than recommended preoperative fasting period and (v) upper gastrointestinal endoscopy overuse in surgical patients without an adequate clinical evidence or without the presence of warning signs. Awareness and reflection among participants were improved, leading to high grades in final evaluation. Changes in training regarding quality of care and cost awareness should start throughout undergraduate training, within a learning environment focused on a reflective and evidence-based practice. All the benefits and harms to patients were taken into account in the recommendations that emerged from this study. The inclusion of this initiative in the General Surgery residency, involving reflective discussions on campaign recommendations regarding procedures frequently used in clinical practice, with no benefits and involving unnecessary risks for patients may lead to more cost-conscious procedures.

Baseline Performance of Real-World Clinical Practice Within a Statewide Emergency Medicine Quality Network: The Michigan Emergency Department Improvement Collaborative (MEDIC)

Large-scale quality and performance measurement across unaffiliated hospitals is an important strategy to drive practice change. The Michigan Emergency Department Improvement Collaborative (MEDIC), established in 2015, has baseline performance data to identify practice variation across 15 diverse emergency departments (EDs) on key emergency care quality indicators. MEDIC is a unique physician-led partnership supported by a major third-party payer. Member sites contribute electronic health record data and trained abstractors add supplementary data for eligible cases. Quality measures include computed tomography (CT) appropriateness for minor head injury, using the Canadian CT Head Rule for adults and Pediatric Emergency Care Applied Network rules for children; chest radiograph use for children with asthma, bronchiolitis, and croup; and diagnostic yield of CTs for suspected pulmonary embolism. Baseline performance was established with statistical process control charts. From June 1, 2016, to October 31, 2017, the MEDIC registry contained 1,124,227 ED visits, 23.2% for children (<18 years). Overall baseline performance included the following: 40.9% of adult patients with minor head injury (N=11,857) had appropriate CTs (site range 24.3% to 58.6%), 10.3% of pediatric minor head injury cases (N=11,183) exhibited CT overuse (range 5.8% to 16.8%), 38.1% of pediatric patients with a respiratory condition (N=18,190) received a chest radiograph (range 9.0% to 62.1%), and 8.7% of pulmonary embolism CT results (N=16,205) were positive (range 7.5% to 14.3%). Performance varied greatly, with demonstrated opportunity for improvement. MEDIC provides a robust platform for emergency physician engagement across ED practice settings to improve care and is a model for other states.

P149: Benign headache management in Alberta emergency departments: a chart review study to explore gaps in practice

Introduction: Variation in medication management and image ordering for HA presentation to emergency departments (ED) has been documented. This study examined benign HA (i.e., migraine, cluster, tension) management in order to identify the consistency and appropriateness of HA management in EDs in Alberta. Methods: Patients were identified by primary discharge diagnosis in the National Ambulatory Care Reporting System using ICD-10-CA codes for benign HA (G43, G44, R51). Patients presenting to study sites from January 1, 2017 to September 30, 2017 were eligible for inclusion, provided they were adults (≥18 years), were not transferred from another institution or directly admitted to a service, and had an active HA at presentation. One hundred eligible patients were randomly selected for chart review. Data were extracted on standardized forms. Preliminary data on 50 patients (n = 150) from three Edmonton study sites is presented. Results: Most patients arrived to the ED via personal transportation (93%) and were assigned a Canadian Triage and Acuity Scale (CTAS) score of 3 (71%). The majority of patients were female (75%); mean age was 45 years (standard deviation: 18). Triage pain score was not documented for 21%. When documented, pain scores were most frequently between 4 and 7 (49%). Nearly 10% of patients left without being seen. For those who were assessed, physicians most frequently used ketorolac and metoclopramide as first or second line treatments or as a combination treatment. Consults were infrequent (14%). Nearly half of the patients (47%). had computed tomography (CT) in the ED. Pain re-assessment was completed for 69% of patients. Most patients were discharged from the ED (88%) and given some form of discharge instruction (78%). The most common instructions were to return to ED as needed (45%) and follow-up with their primary care physician (28%). Across all patients, 13% returned to the ED with headache within 30 days. Conclusion: Physicians treat patients with benign headaches appropriately and hospitalization is infrequent; however, one in eight patients relapse. Missing pain scale documentation reveals a potential problem for ED clinicians in assessing management effectiveness and ensuring patients leave the ED following pain relief. Half of the patients received a CT scan, highlighting the urgent need for an intervention to address CT overuse for patients with benign HA within this geographic region.

Multi-centre study found that strict adherence to guidelines led to computed tomography scans being overused in children with minor head injuries.

Our primary aim was to calculate the head computed tomography (CT) scan rate in children with a minor head injury (MHI) when the Dutch National guidelines were followed in clinical practice. The secondary aim was to determine the incidence of CT abnormalities and the guideline predictors associated with traumatic abnormalities. We performed a multi-centre, prospective observational cross-sectional study in the emergency departments of six hospitals in The Netherlands between 1 April 2015 and 31 December 2016. Data on 1002 patients were studied and 69% of cases complied with the guidelines. The overall CT rate was 44% and the incidence of traumatic abnormal CT findings was 13%. CT scans were performed in 19% of children under two years of age, 48% of children between two and five years and 63% of children aged six years or more. Multivariate regression analysis for all age categories showed that CT abnormalities were predicted by a Glasgow Coma Scale of less than 15, suspicion of a basal skull fracture, vomiting and scalp haematomas or external lesions of the skull. Strict adherence to the Dutch national guidelines resulted in CT overuse. New guidelines are needed to safely reduce CT scan indications.

Use of computed tomography and diffusion weighted imaging in children with ventricular shunt.

To evaluate the indications, number, and imaging results of brain computed tomography (CT) and diffusion weighted imaging (DWI) in children with ventriculoperitoneal shunt, to estimate the radiation dose, and to evaluate the effectiveness of DWI. This retrospectively study included 54 consecutive patients (boys/girls = 30/24, mean age, 3 ± 4.1years) with shunt that were placed due to congenital abnormalities-hypoxic ischemic encephalopathy between January 2015 and March 2018. The presence of shunt-related complications (SRC) was assessed using clinical and neuroimaging findings, and the standard reference was accepted as the shunt revision. Size comparisons of ventricles were performed using Evans index and the frontal and occipital horn ratio, and each measurement made by the observers were compared using Bland-Altman analysis. A kappa coefficient and the intraclass correlation coefficient were calculated to assess the agreement between observers. The mean number of hospital admission, number of CT scans, and DWI were 5.8, 4.8, and 1.1, respectively per patient. A significant linear correlation was observed between hospital admission and CT scans (r = 0.288, p = 0.035). The number of CT scans and the cumulative effective dose per patient were higher in patients with SRC than in those without (p < 0.001). The mortality rate due to radiation-induced neoplasia has increased by 0.33% in the study period. The inter-observer agreement was perfect or substantial for the catheter visualization, assessment of the ventricular system on DWI, and for the image quality of DWI between observers (κ = 0.704-1, p ≤ 0.001). No significant difference was found between CT and DWI in the measurements of Evans index and the frontal and occipital horn ratio (p> 0.05). Inter-observer agreements between observers were almost perfect for the Evans index and the frontal and occipital horn ratio (ICC = 0.94-0.99, p< 0.001). An awareness of the use of CT in children is still inadequate and difficulties in the diagnosis of SRC probably cause the overuse of CT. DWI should be preferred in the diagnosis of SRC and the follow-up of patients. Otherwise, the increase in the prevalence of several diseases, particularly neoplasia, may be inevitable because of the over use of CT.

Overutilization of Computed Tomography for Odontogenic Infections

There is clear overuse of computed tomography (CT) in the emergency setting, which is associated with a long-term potential for malignancy. This study aimed to determine the rate of overuse of CT for odontogenic infection workup and the correlation of history and physical examination (H&P) findings to diagnose moderate- to high-risk infections. A retrospective cross-sectional study was implemented to determine the rate of overuse of CT for odontogenic infections. Included patients presented through the emergency department for evaluation of an odontogenic infection. CT was deemed unnecessary if patients presented without "red-flag" signs at physical examination, which included voice change, elevated floor of mouth, signs of inflammation of deep fascial spaces, periorbital edema, nonpalpable inferior border of the mandible, dyspnea, dysphagia or odynophagia, and trismus. Patients could have no evidence of involvement of a moderate- to high-risk space or airway change at CT. Infection severity was low, moderate, or high risk based on anatomic proximity to the airway and critical structures. Sensitivity, specificity, and positive predictive and negative predictive values of H&P findings to predict moderate- to high-risk infections were calculated and included 95% confidence intervals. For the 470 included patients, 389 CT scans were performed, with 220 (56.6%) deemed unnecessary. Unnecessary scans were most prevalent in patients with low-risk infections, in whom 284 CT scans were performed, with 222 (78.2%) deemed unnecessary. There was a strong correlation between red-flag signs and moderate- to high-risk infections. There is overuse of CT for odontogenic infections that is most prevalent in low-risk infections without indicative findings in the workup. H&P findings can help accurately diagnose a higher-risk infection before subjecting a patient to CT.

MP66-11 FOLLOW-UP IMAGING PATTERNS AFTER EMERGENCY DEPARTMENT VISITS FOR PEDIATRIC NEPHROLITHIASIS

You have accessJournal of UrologyPediatrics: Testis, Varicocele & Stones1 Apr 2017MP66-11 FOLLOW-UP IMAGING PATTERNS AFTER EMERGENCY DEPARTMENT VISITS FOR PEDIATRIC NEPHROLITHIASIS Jonathan Ellison, Paul Merguerian, Ben Fu, Sarah Holt, Thomas Lendvay, John Gore, and Margarett Shnorhavorian Jonathan EllisonJonathan Ellison More articles by this author , Paul MerguerianPaul Merguerian More articles by this author , Ben FuBen Fu More articles by this author , Sarah HoltSarah Holt More articles by this author , Thomas LendvayThomas Lendvay More articles by this author , John GoreJohn Gore More articles by this author , and Margarett ShnorhavorianMargarett Shnorhavorian More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2026AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Concern exists regarding overuse of computed tomography (CT) children with nephrolithiasis. While guidelines for pediatric nephrolithiasis call for imaging such as plain film of the kidney-ureter-bladder (KUB) or renal ultrasound (US) to minimize ionizing radiation in both initial and follow-up management, little is known regarding follow-up imaging practices. We explored nationwide imaging patterns in children following emergency department (ED) evaluations for nephrolithiasis, hypothesizing that initial imaging choice and need for admission or readmission increase the risk of follow-up CT scans. METHODS Claims from MarketScan (2007-2013), an employer-based dataset of privately insured patients, were used to assess children 1-18 presenting to the ED an acute nephrolithiasis event, defined as no prior ED visits or surgical interventions for nephrolithiasis within 6 months. Independent variables were age, gender, region of care and insurance status, initial imaging modality, need for hospital admission, and return ED visits. Primary outcome was imaging modality 90 days following an encounter. Appropriate imaging was defined as either KUB or US. Using logistic regression, odds for receiving CT or appropriate imaging in follow-up were calculated. RESULTS A total of 871 children with an ED visit for nephrolithiasis met inclusion criteria. Median age was 16 (range 1-18) and the majority of patients were female (550, 63.0%). KUB was the most common initial modality (520, 59.7%) followed by CT (196, 22.5%) and US (150, 17.2%). A total of 282 (30.9%) children received no follow-up imaging. Of children receiving any follow-up imaging, appropriate imaging was obtained in 306 (51.9%) and CT obtained in 283 (48.0%) children. Of children initially receiving a CT, 79 (40.3%) had a CT in follow-up. Predictors for imaging patterns are shown in the Table. CONCLUSIONS Overuse of CT in children with nephrolithiasis is not limited to initial presentation as one third of all children presenting to the ED received a CT in follow-up. Identifiable risk factors for follow-up CT include younger age, complexity of stone event, and region of care. Clinical pathways directing imaging strategies for pediatric nephrolithiasis should focus on follow-up imaging as well as initial evaluation. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e866 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Jonathan Ellison More articles by this author Paul Merguerian More articles by this author Ben Fu More articles by this author Sarah Holt More articles by this author Thomas Lendvay More articles by this author John Gore More articles by this author Margarett Shnorhavorian More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

P134: Evaluating barriers to clinical decision rule integration: a qualitative analysis

Introduction: Clinical decision rules for computed tomography (CT) ordering in pulmonary embolism and mild traumatic brain injury have been shown to be under-used in clinical practice. Current literature does not explain why these validated decision rules continue to be under-used despite evidence of inappropriate use and increased costs. To better evaluate potential barriers to their use, qualitative methods involving focused interviews were conducted amongst emergency department (ED) physicians. Methods: Physicians were recruited via a brief presentation at Calgary Zone ED rounds. Ten attending and resident physicians (4 female, 6 male) were interviewed. Questions were designed to evaluate potential barriers to the integration of decision rules into the computerized order entry system. Interviews were audio-recorded and transcribed manually. A high-level thematic analysis was conducted to draw primary themes from open-ended questions, and responses were totaled for closed-ended questions. Results: Emerging themes suggest concerns surrounding timing of rule application in relation to test ordering, patient influences on ordering, and overuse reporting. All 10 physicians believed decision rules for CT ordering play a large role in the ED, and 8 were in favor of integration into the order entry system. However, over half expressed concern, noting that their thought process begins before order entry. A majority prioritized shared decision-making with patients. However, 8 indicated that patient expectations influence their ordering. A majority agreed that there is CT overuse in the ED, but many were hesitant in concluding that overuse was primarily physician dependent. Conclusion: Primary barriers to decision rule integration are timing of application, hesitation surrounding patient input, and uncertainty over data. Physicians often make decisions prior to order entry. Mobile copies of decision rules should be available to better facilitate compliance. Concerns over patient influence on ordering are common. Patient-friendly materials on clinical decision rules should be available to better facilitate shared decision making while still promoting decision rules. While overuse is agreed upon, many prefer to see and track their own ordering data before supporting a physician-targeted intervention. Data reports to physicians may help affirm physician-associated overuse, and reinforce their role in responsible resource utilization.

Role of FAST or Abdominal Ultrasound to Limit CT Imaging in Evaluation of the Pediatric Abdominal Trauma Patient

Blunt abdominal trauma (BAT) can produce serious intra-abdominal injuries (IAI) in children. An early diagnosis is important to reduce morbidity and mortality, but pediatric patients sustaining BAT rarely require an operative intervention. Although the computed tomography (CT) scan is currently the best diagnostic tool to detect IAI, increased awareness of the risks of radiation exposure, high costs, and low utility has led to efforts to reduce the use of CT in the workup of pediatric trauma patients. Focused assessment with sonography for trauma (FAST) is an accurate, noninvasive, and rapid method of evaluating patients with BAT. Many institutions have developed criteria using physical signs and common biochemical markers of abdominal injury in combination with FAST as a screening tool to prevent the overuse of CT in children. We review the use of FAST and scoring systems as tools to limit CT imaging in the evaluation of the pediatric abdominal trauma patient.

CT Overuse for Mild Traumatic Brain Injury

Multiple, validated, evidence-based guidelines exist to inform the appropriate use of computed tomography (CT) to differentiate mild traumatic brain injury (MTBI) from clinically important brain injury and to prevent the overuse of CT. Yet, CT use is growing rapidly, potentially exposing patients to unnecessary ionizing radiation risk and costs. A study was conducted to quantify the overuse of CT in MTBI on the basis of current guideline recommendations. A retrospective analysis of secondary data from a prospective observational study was undertaken at an urban, Level I emergency department (ED) with more than 90,000 visits per year. For adult patients with minor head injury receiving CT imaging at the discretion of the treating physician, the proportion of cases meeting criteria for CT on the basis of the Canadian CT Head Rule (CCHR), American College of Emergency Physicians (ACEP) Clinical Policy, New Orleans Criteria (NOC), and National Institute for Health and Clinical Excellence (NICE) guidelines was reported. All 346 patients enrolled in the original study were included in the analysis. The proportion of cases meeting criteria for CT for each of the guidelines was: CCHR 64.7% (95% confidence interval [CI], 0.60-0.70), ACEP 74.3% (95% CI, 0.70-0.79), NICE 86.7% (95% CI, 0.83-0.90), and NOC 90.5% (95% CI, 0.87-0.94). The odds ratio of the guidelines for predicting positive head CT findings were also reported. Some 10%-35% of CTs obtained in the ED for MTBI were not recommended according to the guidelines. Successful implementation of existing guidelines could decrease CT use in MTBI by up to 35%, leading to a significant reduction in radiation-induced cancers and health care costs.

Increased Emergency Department Computed Tomography Use for Common Chest Symptoms Without Clear Patient Benefits

The aim of this study was to examine changes in the utilization of computed tomography (CT) in the evaluation of common chest symptoms and the rate of clinically significant diagnoses in emergency departments after 2004. This study analyzed the National Hospital Ambulatory Medical Care Survey, comparing 1997 to 1999 and 2005 to 2007. Set in US emergency departments, individuals older than 14 years old were eligible. The main outcome was proportion of common chest symptom-related visits (n = 17,098) associated with a CT order before 2000 and after 2004. Secondary outcomes were the proportion of these visits associated with a clinically significant diagnosis (pulmonary embolism, acute myocardial infarction, acute coronary syndrome, heart failure, pneumonia, and pleural effusion); an incidental diagnosis such as lung mass; and a clinically nonsignificant diagnosis such as nonspecific chest pain. The proportion of common chest symptom-related visits associated with a CT order increased from 2.1% in 1997 to 1999 to 11.5% in 2005 to 2007 (P < .001), whereas the overall proportion of these visits associated with a clinically significant diagnosis decreased from 23.6% in 1997 to 1999 to 19.1% in 2005 to 2007 (P < .001).The rate of acute myocardial infarction diagnosis decreased from 6.6% to 3.3% (P < .001), whereas the rate of pulmonary embolism diagnosis did not change (0.33% vs. 0.47%; P = .24) from 1997 to 1999 to 2005 to 2007. The rate of incidental diagnoses did not change (0.13% vs. 0.17%; P = .69), whereas the rate of clinically nonsignificant diagnoses increased from 35.6% to 45.8% (P < .001) from 1997 to 1999 to 2005 to 2007. CT ordering in emergency departments for the evaluation of common chest symptoms has increased dramatically without improving the rate of pulmonary embolism or other clinically significant diagnoses. Overuse of CT exposes patients to radiation and increases health care costs without any apparent diagnostic benefit.

Radiology's ethical responsibility for healthcare reform: Tempering the overutilization of medical imaging and trimming down a heavyweight

In this review we describe the problem of overutilization of high-cost imaging modalities, especially magnetic resonance imaging (MRI) and computed tomography (CT). The overuse of CT is numerically more dramatic and also carries with it the not insignificant risk of harm to patients, namely, induction of radiation-induced malignancies. We report what is known of these risks in various imaging scenarios. The use of Radiology Business Managers is described as a means adopted to control overuse and the limitations of this strategy. The imperative of appropriate utilization is focused on, with emphasis placed on computer-based medical decision support. Impediments to appropriate use, however, exist, with concerns of medicolegal liability high on the list of these issues. Finally, we recommend that radiologists take the lead in the reform process by implementing strategies such as decision support.