IntroductionOver 40 000 CT scans are performed in our emergency department (ED) annually and utilisation is over 80% capacity. Improving medical appropriateness of CT scans may reduce total number of scans, time, cost and radiation exposure.MethodsLean Six Sigma methodology was used to improve the process. A National Emergency X-Radiography Utilisation Study (NEXUS)-based PowerForm was implemented in the electronic health record and providers were educated on the criteria.ResultsThe rate of potentially medically inappropriate CT C-spine scans decreased from 45% (19/42) to 22% (90/403) (two-proportion test, p=0.002). After the intervention, there was no longer a difference between midlevel providers and physicians in the rate of medically inappropriate orders (19% vs 22%) (two-proportion test, p=0.850) compared with that before the intervention (56% vs 31%) (two-proportion test, p<0.01). Overall rates of CT C-spine scans ordered decreased from 69.3 to 62.6/week (t-test, p=0.019).ConclusionA validated clinical decision-making tool implemented into the medical record can improve quality of care. This study lays a foundation for other imaging studies with validated support tools with similar potential improvements.

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INTRODUCTION: While surgical resection has been shown to improve short-term local disease control, it remains debated whether surgical resection is associated with improved overall survival in patients with malignant primary osseous spinal neoplasms. We reviewed survival data from a US cancer registry spanning 30 years to determine if surgical resection was independently associated with overall survival.METHODS: The SEER registry was queried to identify cases of histologically confirmed primary spinal chordoma, chondrosarcoma, osteosarcoma, or Ewing's sarcoma of the mobile spine and pelvis via ICD-O-2 coding. Patients with systemic metastasis were excluded. Age, sex, race, tumor location, and primary treatments were identified. Extent of local tumor invasion was classified as confined within periosteum vs extension beyond periosteum to surrounding tissues. The association of surgical resection with overall survival was assessed via Cox proportional-hazards regression analysis adjusting for age, radiotherapy, and tumor invasiveness.RESULTS: Eight-hundred, twenty-seven patients were identified with non-metastatic primary osseous spinal neoplasms (215 chordoma, 282 chondrosarcoma, 158 osteosarcoma, 172 Ewing's sarcoma). Overall median survival was histology specific (chordoma: 96 months, Ewing's sarcoma: 90 months, chondrosarcoma: 88 months, osteosarcoma: 18 months). Adjusting for age, radiation therapy, and extent of local tumor invasion in patients with isolated (non-metastatic) spine tumors, surgical resection was independently associated with significantly improved survival for chordoma (Hazard Ratio [95% confidence interval (CI); 0.617 (0.25-0.98)], chondrosarcoma (HR [95%CI]; 0.153 [0.07-0.36]), osteosarcoma (HR [95%CI]; 0.382 [0.21-0.69]), and Ewing's sarcoma (HR [95%CI]; 0.494 [0.26-0.96]).CONCLUSION: In our analysis of a 30-year US population based cancer registry (SEER), patients undergoing surgical resection of primary spinal chordoma, chondrosarcoma, Ewing's sarcoma, or osteosarcoma demonstrated prolonged overall survival independent of patient age, extent of local invasion, or location. Surgical resection may play a role in prolonging survival in the multi-modality treatment of patients with these malignant primary osseous spinal neoplasms.