Why do we perform CTs in the Emergency Department? It’s fair to say the primary indication is diagnostic certainty: the ruling-in or ruling-out of a disease process of substantial clinical relevance. However, this study begs the question: have we lost touch with this concept of “substantial clinical relevance”?
This is a qualitative study evaluating physician decision-making in the context of CT ordering. These authors provided physicians, approximately 2/3rds attending physicians, a questionnaire pre- and post-CT for 1,280 patients in the Emergency Department. The main gist: what are you worried about? How confident are you in the diagnosis? And, then, after CT, how about now?
The bullet-point summary:
- Physician confidence in their diagnosis grew after CT. Splendid.
- CT excluded or confirmed alternative diagnoses in 95+% of cases. Excellent.
- Increasing pre-CT confidence in a leading diagnosis was associated with lesser changes in leading diagnosis post-CT. OK.
- Many pre-CT leading diagnoses were benign, but with low physician confidence. Except for CT head.
- Nearly 3/4ths of CT scans performed of the head had a leading diagnosis of “Benign headache” or other, had no change in diagnosis following CT, and confidence was generally pretty high. This is awful.
- Finally, if you were hoping a CT would prevent bouncebacks: no. 15% of abdominal pain returned within a month for related reasons, as well as 14% of chest pain/dyspnea, and 11% of headache.
CT is an important tool. It certainly makes the life of the risk-averse physician much, much easier. However, the instances in which CT identified an important diagnosis in this study are certainly in the minority – most final diagnoses were either benign or could have been achieved through other means. Unfortunately, very few specific actionable items can be taken away from this study – excepting CT for headache (ugh) – but it certainly shows there is fertile ground for a culture change to take root and decrease low-yield CT utilization.
“CT in the emergency Department: A Real-Time Study of Changes in Physician Decision Making”