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”
http://www.ncbi.nlm.nih.gov/pubmed/26402399
Interesting summary, thanks. Although bouncebacks were not prevented, I'm curious whether CTs impacted how patients were treated on their return. For example, were they appropriately or inappropriately stratified into low risk ("3rd visit for abdominal pain after a negative CT…")?