Computed Tomography Utilization Rates Research Articles

A Review of Pediatric Appendicitis Imaging Trends from 2006 – 2020 Using the Nationwide Emergency Department Sample

BackgroundAppendicitis is a common surgical emergency in the pediatric population, affecting over 70,000 children per year in the United States alone. While historically practitioners predominately used computed tomography (CT) as the main diagnostic imaging modality, multiple professional societies have released guidelines recommending an ultrasound (US) first strategy when using imaging to confirm suspected appendicitis in pediatric populations. To date, no studies have quantified the change in imaging trends for pediatric appendicitis across the spectrum of healthcare facilities in the United States utilizing the Nationwide Emergency Department Sample (NEDS). ObjectivesWe aimed to evaluate the imaging trends for pediatric appendicitis across the nation, stratified by age and gender. Specifically, we wanted to delineate the use of CT alone versus US alone or US first imaging strategies. MethodsThis retrospective cross-sectional study utilized data from the NEDS spanning from 2006 through 2020. We examined and analyzed the total number of patients, the number of patients with available imaging data, sex, age, and included imaging modalities utilizing descriptive statistics and regression analyses. Similarly, regression analysis was employed to discern differences in imaging rates in time intervals following societal imaging recommendations. ResultsFrom 2006 to 2020 the database recorded 160,828 encounters for pediatric appendicitis. Imaging data was available for 101,248 encounters, accounting for 63% of the total sample. Over the study period, both rates of ‘US only’ and ‘US first’ imaging modalities increased (from 5.5% to 38.9% and 8.9% to 55.6%, respectively), while rates of CT utilization in isolation declined (from 91.1% to 44%). ConclusionWhile there is an increasing trend towards US being used as the first imaging modality to diagnose pediatric appendicitis across the spectrum of facilities included in the NEDS, continued utilization of CT to diagnose appendicitis remains unacceptably high in the pediatric population within the limits of this retrospective study.

Effect of an Evaluation Algorithm on CT Utilization in Identifying Appendicitis in Children.

Our objective was to determine if there was a significant change in computed tomography (CT) utilization or length of stay (LOS) among patients evaluated for acute appendicitis after implementation of an appendicitis evaluation algorithm. We conducted a retrospective chart review of patients aged 3-18 years in an urban, tertiary pediatric emergency department with acute abdominal pain, evaluated for appendicitis. Data were collected for 6 months preimplementation and postimplementation of the evaluation algorithm with a 3-month washout period between September 2018 and November 2019. Main outcomes were rate of CT utilization and LOS preimplementation and postimplementation and were analyzed using χ 2 test and Mann-Whitney U test, respectively. Descriptive analysis of demographics was performed, in addition to logistic regression to assess differences between the 2 study periods. A total of 2872 charts were identified with a chief complaint inclusive of "abdominal pain." Of these, 1510 met age requirements but did not meet at least 1 inclusion criteria; 229 more were excluded upon chart review for a final study sample of 1133 patients. Of these, 648 (57.2%) were female, 747 (65.9%) were White, and 988 (87.2%) were non-Hispanic. The majority of patients (770, 68%) were discharged home from the emergency department without a diagnosis of acute appendicitis. Neither CT (25.7% to 24.8%; P = 0.794) nor ultrasound (59.5% to 59.7%; P = 1.000) utilization significantly changed postimplementation. Total ED median LOS increased significantly (333.50 to 362.00 minutes; P = 0.011). Significant factors associated with CT utilization included fever, migration of pain, and right lower quadrant tenderness. Significant factors associated with appendicitis diagnosis included right lower quadrant pain, nausea/vomiting, migration of pain, and peritoneal signs. Overall, the appendicitis evaluation algorithm did not significantly decrease CT utilization or LOS. Equivocal grade 2 or 3 ultrasound finding rates were high, likely leading to higher rates of CT utilization and increasing LOS.

A76 PHYSICIANS PERCEIVED VALUE OF COMPUTED TOMOGRAPHY SCANS FOR INFLAMMATORY BOWEL DISEASE PATIENTS IN THE EMERGENCY DEPARTMENT: A SURVEY OF CANADIAN PHYSICIANS

Abstract Background Despite concerns regarding the risks of ionizing radiation from computed tomography (CT) imaging, the rates of abdominal pelvic CT (APCT) utilization in the emergency department (ED) continues to increase for patients with inflammatory bowel disease (IBD). Purpose To determine the factors that drive decisions on when to perform APCT imaging in the ED for patients with IBD and to determine if differences exist between physician specialties. Method We performed a quantitative, web-based survey between November 2021 and August 2022. Structured questions for Crohn’s disease (CD) and ulcerative colitis (UC) were developed with input from stakeholders in gastroenterology, surgery, and emergency medicine. Surveys were disseminated to Canadian physicians in each of the three specialities through personal emails, and by newsletter from national specialty organizations. Between specialty comparisons were performed by Chi-squared and Fisher exact tests where appropriate. Result(s) A total of 208 participants responded to our survey: median age 44 years (IQR 37-50), 132 (63%) male, and 141 (68%) in an academic practice. Survey participants included 81 (39%) gastroenterologists, 35 (17%) surgeons and 92 (44%) emergency physicians. There were significant differences between specialties in the perceived rates of positive findings from APCT imaging. In UC, gastroenterologists felt inflammation alone was more common than emergency physicians and bowel obstruction and septic complications less common than surgeons and emergency physicians. In CD, surgeons felt bowel obstructions, septic complications and bowel perforations were more common compared with gastroenterologists and emergency physicians. There were significant differences between specialties in the types of clinical presentations that drove decisions to arrange APCT imaging (Figure 1a&b). In UC, gastroenterologists were less likely to order APCT imaging for diarrhea with rectal bleeding, abdominal pain without peritoneal findings and fever than surgeons and emergency physicians. In CD, there were similar practice patterns between specialities except gastroenterologists were less likely to order APCT imaging for diarrhea with rectal bleeding than surgeons. Image Conclusion(s) Our survey identified key differences between physician specialties in the perceived rates of positive findings from APCT imaging and practice patterns of CT utilization. These findings will help to guide the development of future multidisciplinary consensus guidelines for the appropriateness of CT imaging in the ED for patients with IBD. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Persistently High Rates of Abdominal Computed Tomography Imaging Among Patients With Inflammatory Bowel Disease Who Present to the Emergency Department.

Recent guidelines recommended judicious use of abdominal computed tomography (CT) in the emergency department (ED) for inflammatory bowel disease. Trends in CT utilization over the last decade, including since the implementation of these guidelines, remain unknown. We performed a single-centre, retrospective study between 2009 and 2018 to assess trends in CT utilization within 72 h of an ED encounter. Changes in the annual rates of CT imaging among adults with IBD were estimated by Poisson regression and CT findings by Cochran-Armitage or Cochran-Mantel Haenszel tests. A total of 3000 abdominal CT studies were performed among 14,783 ED encounters. CT utilization increased annually by 2.7% in Crohn's disease (CD) (95% confidence interval [CI], 1.2 to 4.3; P = 0.0004), 4.2% in ulcerative colitis (UC) (95% CI, 1.7 to 6.7; P = 0.0009) and 6.3% in IBD unclassifiable (95% CI, 2.5 to 10.0; P = 0.0011). Among encounters with gastrointestinal symptoms, 60% with CD and 33% with UC underwent CT imaging in the final year of the study. Urgent CT findings (obstruction, phlegmon, abscess or perforation) and urgent penetrating findings alone (phlegmon, abscess or perforation) comprised 34% and 11% of CD findings, and 25% and 6% of UC findings, respectively. The CT findings remained stable overtime for both CD (P = 0.13) and UC (P = 0.17). Our study demonstrated persistently high rates of CT utilization among patients with IBD who presented to the ED over the last decade. Approximately one third of scans demonstrated urgent findings, with a minority demonstrating urgent penetrating findings. Future studies should aim to identify patients in whom CT imaging is most appropriate.

CT Utilization in a Level One Trauma Center in South Africa.

IntroductionComputed tomography (CT) imaging forms an important component in the evaluation and management of patients with traumatic injuries. Many South African emergency departments (EDs) have a significant trauma-related workload, especially in the public sector, where there are limitations in resources relating to CT scanners. It is important to gauge the impact of traumatic injuries on CT utilization. The primary objectives were to quantify the number and type of CT imaging studies trauma patients received, as well as to determine the frequency of radiologically significant findings in a level one trauma center. The secondary objectives were to determine the CT utilization rate and describe the demographics of patients who received imaging.MethodsThis was a retrospective, quantitative, descriptive, cross-sectional study undertaken over two months at the level one trauma center of a tertiary, academic, public sector teaching hospital in Johannesburg, South Africa. The radiology department’s picture archiving and communication system (PACS) was used to evaluate the reports of trauma patients who were referred for a CT scan. The trauma center register was used to calculate the CT utilization rate.ResultsThere were 5,058 trauma patients seen in the two months. A total of 1,277 CT scans were performed on 843 patients. CT brain accounted for 52% of all scans performed. Radiologically significant findings were demonstrated in 407 scans (354 patients), i.e. 31.9% of scans and 42% of patients. CT chest and peripheral angiogram demonstrated radiologically significant findings in 60.5% and 50.9% of scans respectively. Assault accounted for 55.8% of the injuries sustained and road traffic accidents accounted for 33.2%. The overall CT utilization rate was 16.7% i.e. 843 out of the 5,058 trauma patients underwent a CT scan.ConclusionsSouth Africa has a substantial trauma burden which commonly necessitates CT utilization. It is concerning that blunt and penetrating assault continues to dominate these traumatic presentations. Worldwide, there is a broad range of described CT utilization rates and the findings at this level one trauma center fall within that range. ED clinicians are encouraged to continue carefully using this scarce resource in the trauma setting.

Barriers and facilitators of CT scan reduction in the workup of pediatric appendicitis: A pediatric surgical quality collaborative qualitative study

IntroductionDespite ongoing efforts to decrease ionizing radiation exposure from computed tomography (CT) use in pediatric appendicitis, high CT utilization rates are still observed across many hospitals. This study aims to identify factors influencing CT use and facilitators and barriers to quality improvement efforts. MethodsThe Pediatric Surgery Quality Collaborative is a voluntary consortium of 42 children's hospitals participating in the National Surgical Quality Improvement Project - Pediatric. Hospitals were compared based on CT utilization from January 1, 2019, to December 31, 2019. Semi-structured interviews were conducted with surgeons, radiologists, emergency medicine physicians, and clinical data abstractors from 7 hospitals with low CT use rates (high performers) and 6 hospitals with high CT use rates (low performers). A mixed deductive and inductive coding approach for analysis of the interview transcripts was used to develop a codebook based on the Theoretical Domains Framework and subsequently identify prominent barriers and facilitators to CT reduction. ResultsThematic saturation was achieved after 13 interviews. We identified four factors that distinguish high-performing from low-performing hospitals: (1) consistent availability of resources such as ultrasound technicians, pediatric radiologists, and magnetic resonance imaging (MRI); (2) presence of and adherence to protocols guiding imaging modality decision making and imaging execution; (3) culture of inter-departmental collaboration; and (4) presence of a radiation reduction champion. ConclusionsSignificant barriers to reducing the use of CT in pediatric appendicitis exist. Our findings highlight that future quality improvement efforts should target resource availability, protocol adherence, collaborative culture, and radiation reduction champions. Levels of EvidenceLevel III

Variation in imaging outcomes associated with individual sonographers and radiologists in pediatric acute appendicitis: a retrospective cohort of 9271 examinations

To determine if individual sonographers and radiologists impact appendix visualization by ultrasound and utilization of computed tomography (CT) in children with suspected acute appendicitis. Appendix ultrasound examinations performed at Cincinnati Children's Hospital Medical Center on Emergency Department patients ≤ 18 years old were retrospectively identified. Examinations performed/interpreted by sonographers/radiologists with fewer than 100 examinations were excluded. Multivariable logistic regression was used to assess the effect of sonographer, radiologist, clinical variables, and system factors on imaging outcomes, including appendix visualization and subsequent CT utilization. A total of 9271 ultrasound examinations (mean [SD] patient age, 9.9 [4.2] years; 5392 [58.2%] boys) performed by 31 sonographers (mean number examinations, 299 [139]; range, 115-610) and interpreted by 31 radiologists (mean number examinations, 299 [157]; range, 101-845) were included. The mean frequency of appendix visualization per sonographer was 57.8% [8.7%] (range, 40.9-76.0%) and per radiologist was 59.5% [4.1%] (range, 51.7-66.3%). The mean rate of CT utilization per sonographer was 9.2% [2.0%] (range, 5.9-14.0%) and per radiologist was 9.2% [1.8%] (range, 3.4-12.1%). Predictors of appendix visualization by ultrasound included patient weight (p < 0.0001), sex (p = 0.0003), white blood cell count (p < 0.0001), temperature (p = 0.002), abdominal tenderness (p = 0.004), presence of appendicitis (p < 0.0001), sonographer (p < 0.0001), and radiologist (p = 0.02). Predictors of CT utilization included patient weight (p < 0.0001), white blood cell count (p < 0.0001), abdominal tenderness (p < 0.0001), rebound tenderness (p = 0.0003), and presence of appendicitis (p < 0.0001), but not sonographer or radiologist. Individual sonographers and radiologists were associated with appendix visualization by ultrasound in children with suspected acute appendicitis; neither was associated with CT utilization. • Individual sonographers and radiologistsare significantly and independently associated with appendix visualization by ultrasound in children with suspected acute appendicitis. • Frequency of appendix visualization per sonographer demonstrated significant and wide variability across 31 sonographers, ranging from 40.9 to 76.0%. • Fewer than 10% of patients with an ultrasound examination for suspected acute appendicitis underwent CT imaging within the following 24 h. Individual radiologists and sonographers were not predictive of CT utilization within 24 h.

Reducing Computed Tomography Scan Utilization for Pediatric Minor Head Injury in the Emergency Department: A Quality Improvement Initiative.

The validated Pediatric Emergency Care Applied Research Network (PECARN) prediction rules are meant to aid clinicians in safely reducing unwarranted imaging in children with minor head injuries (MHI). Even so, computed tomography (CT) scan utilization remains high, especially in intermediate-risk (per PECARN) MHI patients. The primary objective of this quality improvement initiative was to reduce CT utilization rates in the intermediate-risk MHI patients. This project was conducted in a Level I trauma pediatric emergency department (ED). Children<18years evaluated for intermediate-risk MHI from June 2016 through July 2019 were included. Our key drivers were provider education, decision support, and performance feedback. Our primary outcome was change in head CT utilization rate (%). Balancing measures included return visit within 72hours of the index visit, ED length of stay (LOS), and clinically important traumatic brain injury (ciTBI) on the revisit. We used statistical process control methodology to assess head CT rates over time. A total of 1,535 eligible intermediate-risk MHI patients were analyzed. Our intervention bundle was associated with a decrease in CT use from 18.5% (95% confidence interval [CI]=14.5% to 22.5%) in the preintervention period to 13.9% (95% CI=13.8% to 14.1%) in the postintervention period, an absolute reduction of 4.6% (p=0.015). Over time, no difference was noted in either ED LOS or return visit rate. There was only one revisit with a ciTBI to our institution during the study period. Our multifaceted quality improvement initiative was both safe and effective in reducing our CT utilization rates in children with intermediate-risk MHI.

Randomized control trial comparing an Alvarado Score-based management algorithm and current best practice in the evaluation of suspected appendicitis

BackgroundAn objective algorithm for the management of suspected appendicitis guided by the Alvarado Score had previously been proposed. This algorithm was expected to reduce computed tomography (CT) utilization without compromising the negative appendectomy rate. This study attempts to validate the proposed algorithm in a randomized control trial.MethodsA randomized control trial comparing the management of suspected acute appendicitis using the proposed algorithm compared to current best practice, with the rate of CT utilization as the primary outcome of interest. Secondary outcomes included the percentage of missed diagnosis, negative appendectomies, length of stay in days, and overall cost of stay in dollars.ResultsOne hundred sixty patients were randomized. Characteristics such as age, ethnic group, American Society of Anesthesiologist score, white cell count, and symptom duration were similar between the two groups. The overall CT utilization rate of the intervention arm and the usual care arm were similar (93.7% vs 92.5%, p = 0.999). There were no differences in terms of negative appendectomy rate, length of stay, and cost of stay between the intervention arm as compared to the usual care arm (p = 0.926, p = 0.705, and p = 0.886, respectively). Among patients evaluated with CT, 75% (112 out of 149) revealed diagnoses for the presenting symptoms.ConclusionThe proposed AS-based management algorithm did not reduce the CT utilization rate. Outcomes such as missed diagnoses, negative appendectomy rates, length of stay, and cost of stay were also largely similar. CT utilization was prevalent as 93% of the study cohort was evaluated by CT scan.Trial registrationThe study has been registered at ClinicalTrials.gov (NCT03324165, Registered October 27 2017).

Minimizing Ionizing Radiation in Evaluating Suspected Appendicitis in Children Before and After the Release of the ACEP Clinical Policy.

The aim of this study was to examine the impact of the ACEP (American College of Emergency Physicians) clinical policy regarding diagnosis of suspected appendicitis on changing practice in the pediatric emergency department (ED) in the absence of a formal departmental protocol. This was a retrospective chart review in a pediatric ED in which patients aged 2 to 18 years were evaluated for appendicitis via ultrasound, computed tomography (CT), or both, over a 7-year study period. We compared rates of CT utilization in the period before the release of the ACEP clinical policy regarding diagnosis and treatment of appendicitis (2008-2009) and the period after (2010-2014). Other metrics of interest were ultrasound results and physician response to results, as well as surrogate markers for quality of care. Seven hundred pediatric ED visits were included, with 200 prepolicy release and 500 postrelease. Computed tomography utilization decreased significantly postpolicy release from 43.5% (95% confidence interval [CI], 36.6%-50.3%) to 22.2% (95% CI, 18.5%-25.8%). The proportion of ultrasounds with indeterminate results also decreased, with 71.5% (95% CI, 65.1%-77.9%) and 55.1% (95% CI, 50.7%-59.5%) in the pre and post groups, respectively. Physicians ordered fewer CTs after indeterminate ultrasounds, decreasing from 63.7% (95% CI, 56.9%-70.5%) to 48.3%% (95% CI, 43.9%-52.7%). After the release of the clinical policy, CT utilization decreased significantly suggesting possible effectiveness of the policy in bringing about change in practice. Subsequently, there was an increase in the definitiveness in the ultrasound results. Physicians also evolved in their response to indeterminate ultrasound results, with fewer CTs ordered reflexively after indeterminate results.

Utilization of computed tomography imaging in the pediatric emergency department.

In recent years, there has been a movement toward more judicious use of computed tomography (CT) imaging in an attempt to limit exposure of pediatric patients to ionizing radiation. The Image Gently Alliance and like-minded movements began advocating for safe and high-quality pediatric imaging worldwide in the late 2000s. In the context of these efforts, we evaluate CT utilization rates in the pediatric emergency department at a major academic medical center. We tracked utilization in several categories of CT, magnetic resonance imaging (MRI) and ultrasonography (US) between July 2008 and June 2017 and compared them with utilization rates from 2000 to 2006. A total of 4,955 pediatric patients underwent a total of 5,973 CT scans, 2,775 US studies and 293 MRI scans while in the pediatric emergency department during the 2008-2017 study period. We observed decreases in CT scans across all categories, ranging from a 19% decrease in abdominal CT to a 66% decrease in chest CT. Relatively greater decreases in CT scans were observed in patients younger than 3years of age as compared to older children and adolescents. Abdominal and pelvic US increased. Brain MRI also increased over the final two years of the study. CT utilization decreased throughout the 2008-2017 study period.

Reducing emergency department (ED) computed tomography (CT) utilization in women treated for gynecologic cancers

ObjectivesThe objective of this quality improvement (QI) project was to decrease the rate of low-value computed tomography (CT) imaging in established gynecologic oncology patients presenting to the emergency department (ED). MethodsThis was a cohort study with a before and after design that evaluated implementation of a QI project designed to decrease CT utilization in established gynecologic oncology patients in the ED. The pre-intervention cohort included patients admitted through the ED from 4/1/17 to 5/31/18, while the post-intervention cohort was from 6/1/18 to 5/31/19. The intervention included gynecologic oncology consultation before CT on patients who had imaging within the prior 3 weeks. Details regarding CT, ED length of stay (LOS), and oncologic history were abstracted. The value of CT was determined by consensus from 2 reviewers. Prospective data monitoring evaluated for patient safety. ResultsPrior to intervention, there were 129 unique ED encounters in gynecologic oncology patients leading to admission. CT scans were performed in 101 (78.3%) encounters, 57.7% of which were deemed to be of low-value. Following implementation, the CT utilization rate decreased significantly from median monthly rate of 75.2% to 49.1% (p < 0.00001), and the ED LOS decreased from 8.1 to 6.9 h (p = 0.0102). The number of CT scans deemed to be low-value in the post-intervention group decreased to 2 (3.8%). ConclusionsImplementation of an early consultation policy and imaging guidelines led to a significant decrease in unnecessary CT utilization and shorter ED LOS in gynecologic oncology patients presenting to the ED.

A clinical pathway to minimize computed tomography for suspected nephrolithiasis in children

Ultrasound (US) imaging is preferred in the initial evaluation for children with suspected nephrolithiasis; however, computed tomography (CT) continues to be used in this setting with resultant unnecessary ionizing radiation exposure. The study institution implemented a standardized clinical pathway to reduce rates of CT utilization for children with nephrolithiasis. The aim of this study was to evaluate the impact of this pathway on initial imaging strategies for children with suspected nephrolithiasis. A standardized pathway was designed and implemented using a systematic quality improvement process. A suspected cohort was created using 'reason for study'search terms consistent with a nephrolithiasis diagnosis. A confirmed cohort of children with a final diagnosis of nephrolithiasis was derived from this suspected cohort. The primary outcome was CT use as the initial imaging study in children with suspected or confirmed nephrolithiasis presenting to the emergency department (ED) between October 2013 and February 2018. Comparisons were made before and after pathway implementation (October 2015). Secondary outcomes included rates of CT scan within 30 days, while balancing measures included rates of admission, ED length of stay, and return visits. A total of 534 children with suspected (220 prepathway; 314 postpathway) and 90 children with confirmed (37 prepathway; 53 postpathway) nephrolithiasis were included. For the suspected cohort, CT scans performed as the initial imaging evaluation (9.2% vs 2.5%, P=0.001) and at any time during the index visit (15.7% vs 5.7%, P=0.001) decreased after pathway implementation. Within the confirmed cohort, a non-significant decrease in initial CT rates was observed after implementation. No differences were observed in admission rates or ED length of stay after implementation. A trend towardlower return visits to the ED was seen after pathway implementation (5.5% vs 2.2%, P=0.058). Within a tertiary care pediatric ED associated with a strong institutional experience with clinical pathways, initial CT rates were decreased after pathway implementation for children with suspected nephrolithiasis. While retrospective assessment of suspected disease is limited, this is one of the first studies to address imaging patterns for nephrolithiasis beyond the final discharge diagnosis, thus capturing a broader cohort of children. Children with suspected nephrolithiasis can be safely managed with an US-first approach, and postvisit CT scans are rarely necessary for management. A standardized clinical pathway for suspected nephrolithiasis can reduce rates of initial and overall CT utilization without adversely impacting downstream care.

Benefits of Computed Tomography in Reducing Mortality in Emergency Medicine.

Performing accurate diagnosis using computed tomography (CT) in emergency medicine may reduce mortality rates in various diseases. In this observational, correlational and cross-sectional study, we conducted multiple regression analyses to investigate the relationship between CT utilization rates and mortality. In addition, we estimated the annual net profits from CT to show the profitability of introducing a CT system in each Japanese prefecture.We conducted a multiple regression analysis to investigate correlations between CT utilization rates and mortality from each disease adjusted for the population density, number of doctors, as well as transportation time to the medical institution.The results of multiple regression analysis showed that traffic accident mortality was related to CT utilization rate and population density. Extrinsic death such as mortality due to falling, drowning and asphyxia was related to CT utilization, indicating that CT in emergency medicine reduced mortality. Moreover, the annual net profit from multi-slice CT (MSCT) was estimated as positive.Our study clearly demonstrates that CT utilization rates relate to a reduction in mortality from accidents, indicating that screening patients with CT in the emergency room has a beneficial effect and reduces mortality. Therefore, CT equipment has a beneficial effect in both emergency medicine and hospital management.

Hospital efficiency and utilization of high-technology medical equipment: A panel data analysis

ObjectiveThe association between hospital characteristics and utilization of high-tech medical equipment has received more attention for its complicated consequences on health care costs and quality. This study aims to take a step further by focusing on the relationship between hospital efficiency and utilization of Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). MethodsWe selected a random sample of 131 hospitals, and conducted a questionnaire survey in each of the sampled hospitals in 2009–2013. We first estimated hospital cost inefficiency scores through stochastic frontier analysis. Then, we examined how the scores as well as population, GDP, hospital volume, annual number of surgical cases and hospital beds were associated with CT and MRI utilization rates through a series of linear regression models with hospital-level fixed effect. We also conducted a series of sensitivity checks to estimate the inefficiency scores or applying different time-lags to the scores in the regression models. ResultsThe descriptive and regression analysis revealed a positive and significant association between the scores and CT (P< 0.01) or MRI (P< 0.05) utilization rate. Regarding other covariates, hospital volume, annual number of surgical cases were significantly associated with CT (P< 0.05), not MRI (P> 0.05) utilization rate. The sensitivity checks confirmed the robustness of the results. ConclusionsUtilization of CT and MRI increased with hospital cost inefficiency. The finding has important policy implication for the ongoing hospital reform in China.

Standardized ultrasound templates for diagnosing appendicitis reduce annual imaging costs

BackgroundUltrasound is preferred over computed tomography (CT) for diagnosing appendicitis in children to avoid undue radiation exposure. We previously reported our experience in instituting a standardized appendicitis ultrasound template, which decreased CT rates by 67.3%. In this analysis, we demonstrate the ongoing cost savings associated with using this template. MethodsRetrospective chart review for the time period preceding template implementation (June 2012-September 2012) was combined with prospective review through December 2015 for all patients in the emergency department receiving diagnostic imaging for appendicitis. The type of imaging was recorded, and imaging rates and ultrasound test statistics were calculated. Estimated annual imaging costs based on pretemplate ultrasound and CT utilization rates were compared with post-template annual costs to calculate annual and cumulative savings. ResultsIn the pretemplate period, ultrasound and CT rates were 80.2% and 44.3%, respectively, resulting in a combined annual cost of $300,527.70. Similar calculations were performed for each succeeding year, accounting for changes in patient volume. Using pretemplate rates, our projected 2015 imaging cost was $371,402.86; however, our ultrasound rate had increased to 98.3%, whereas the CT rate declined to 9.6%, yielding an annual estimated cost of $224,853.00 and a savings of $146,549.86. Since implementation, annual savings have steadily increased for a cumulative cost savings of $336,683.83. ConclusionsStandardizing ultrasound reports for appendicitis not only reduces the use of CT scans and the associated radiation exposure but also decreases annual imaging costs despite increased numbers of imaging studies. Continued cost reduction may be possible by using diagnostic algorithms.

The Association Between Physician Empathy and Variation in Imaging Use.

Variation in emergency physician computed tomography (CT) imaging utilization is well described, but little is known about what drives it. Physician empathy has been proposed as a potential characteristic affecting CT utilization. The objective was to describe empathy in a cohort of emergency physicians and evaluate its association with CT utilization. We also sought to compare emergency physician performance on an empathy psychometric test with performance on other psychometric tests previously proposed as predictors of CT utilization. This cross-sectional study included two parts: 1) a secondary analysis of emergency department (ED) CT imaging utilization data in a large health system from July 2013 to June 2014 and 2) a survey study of the cohort of physicians responsible for this imaging using four psychometric scales: the Jefferson Scale of Empathy (JSE), a risk-taking subset of the Jackson Personality Index (RTS), the Stress from Uncertainty Scale (SUS), and the Malpractice Fear Scale (MFS). The study included data and physicians from four EDs: one urban, academic ED, two community, and one free-standing. A hierarchical, mixed-effects regression model was used to evaluate the association between emergency physician performance on the four scales and risk-adjusted CT imaging utilization. The model incorporated physician-specific CT utilization rates adjusted for propensity scores that were calculated using over 500 patient-level variables via random forest methods, physician demographics, and a random provider effect to account for the clustering of observations. CT variation analysis included 113,517 patients seen during the study period by the 74 eligible emergency physician survey respondents; 20,972 (18.5%) of these patients had at least one CT. The survey response rate was 74 of 82 (90.2%). Correlation coefficients between JSE and the other scales were not statistically significant. In subset analysis, there was a trend toward a physician's number of years in practice and RTS score contributing to CT utilization for traumatic head CT. There were no significant associations between performance on any of the psychometric scales and CT utilization. Performance on the JSE, RTS, SUS, or MFS was not predictive of risk-adjusted CT utilization in the ED. The underlying physician-based factors that mediate interphysician variation remain to be clearly identified.

Trends in CT Utilization for Pediatric Fall Patients in US Emergency Departments

Falls are a common cause of emergency department (ED) visits in the United States. We evaluated trends in computed tomography (CT) utilization for pediatric fall victims in the United States from 2001 to 2010. Using the National Hospital Ambulatory Medical Care Survey from 2001 to 2010, we identified all visits of pediatric (aged <18 years) patients presenting to EDs after falls. This database surveys approximately 500 EDs per year for 4 weeks providing national estimates on ED resource utilization and outcomes. We studied trends in CT utilization and proportion of visits with life-threatening conditions after falls. We also studied the association between CT utilization rates and demographic characteristics and admission status. A total of 9763 unweighted observations for a total of 32,432,686 pediatric fall patients were seen in US EDs from 2001 to 2010. The proportion of pediatric fall patients receiving CT increased from 5.3% in 2001 to a peak of 16.6% in 2009 and decreased to 11.3% in 2010, whereas the proportion of pediatric fall patients with life-threatening conditions fluctuated between 1.2% and 3.3% during this period. In multivariate logistic regression analysis, each increasing year was independently associated with CT utilization (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.14-1.16). Patients aged 0-1 years had higher odds of CT utilization than patients aged 13-17 years (OR, 2.27; 95% CI, 2.26-2.27). There was a twofold increase in CT utilization among pediatric fall visits from 2001 to 2010. When controlling for demographic and clinical variables, increasing year was independently associated with CT utilization. These findings suggest that CT may be overutilized among pediatric fall patients.

Advanced radiology utilization in a tertiary care emergency department from 2001 to 2010.

ObjectiveTo evaluate the utilization trends of advanced radiology, i.e. computed tomography (CT) and magnetic resonance imaging (MRI), examination in an emergency department (ED) of an academic medical center from 2001 to 2010.Patients and MethodsWe assessed the overall CT and MRI utilization, and the ED patient encounters. Each examination was evaluated according to the patient’s age and anatomically relevant regions.ResultsDuring the study period, 737,760 patient visited the ED, and 156,287 CT and 35,018 MRI examinations were performed. The number of annual ED patients increased from 63,770 in 2001 to 94,609 in 2010 (P = 0.018). The rate of CT utilization increased from 105.5 per 1000 patient visits in 2001 to 289.2 in 2010 (P<0.001), and the rate of MRI utilization increased from 8.1 per 1000 patient visits in 2001 to 74.6 in 2010 (P<0.001). In all of the patient age groups, the overall CT and MRI utilization increased. The greater the patient age, the more likely the use of advanced radiology [CT: 87.1 per 1000 patients in age <20 vs. 293.9 per 1000 in age>60 (P<0.001); MRI: 5.1 per 1000 patients in age <20 vs. 108.7 per 1000 in age>60 (P<0.001)]. Abdomen-pelvis (40.2%) and the head (35.7%) comprised the majority of CT scans, while the head (86.4%) comprised the majority of MRI examinations. The rates of advanced radiology use increased across all anatomical regions, with the highest increase being in chest CT (5.9 per 1000 to 49.2) and head MRI (7.2 per 1000 to 61.9).ConclusionWe report a three-fold and nine-fold increase in the use of CT and MRI, respectively, during the study period. Additional studies will be required to understand the causes of this change and to determine the effect of advanced radiology utilization on the patient outcome.

The Effect of Malpractice Reform on Emergency Department Care

BackgroundMany believe that fear of malpractice lawsuits drives physicians to order otherwise unnecessary care and that legal reforms could reduce such wasteful spending. Emergency physicians practice in an information-poor, resource-rich environment that may lend itself to costly defensive practice. Three states, Texas (in 2003), Georgia (in 2005), and South Carolina (in 2005), enacted legislation that changed the malpractice standard for emergency care to gross negligence. We investigated whether these substantial reforms changed practice.MethodsUsing a 5% random sample of Medicare fee-for-service beneficiaries, we identified all emergency department visits to hospitals in the three reform states and in neighboring (control) states from 1997 through 2011. Using a quasi-experimental design, we compared patient-level outcomes, before and after legislation, in reform states and control states. We controlled for characteristics of the patients, time-invariant hospital characteristics, and temporal trends. Outcomes were policy-attributable changes in the use of computed tomography (CT) or magnetic resonance imaging (MRI), per-visit emergency department charges, and the rate of hospital admissions.ResultsFor eight of the nine state–outcome combinations tested, no policy-attributable reduction in the intensity of care was detected. We found no reduction in the rates of CT or MRI utilization or hospital admission in any of the three reform states and no reduction in charges in Texas or South Carolina. In Georgia, reform was associated with a 3.6% reduction (95% confidence interval, 0.9 to 6.2) in per-visit emergency department charges.ConclusionsLegislation that substantially changed the malpractice standard for emergency physicians in three states had little effect on the intensity of practice, as measured by imaging rates, average charges, or hospital admission rates. (Funded by the Veterans Affairs Office of Academic Affiliations and others.)