Abdominal Computed Tomography Utilization and 30-day Revisitation in Emergency Department Patients Presenting With Abdominal Pain

Abstract

Objectives: The objective was to explore which patient characteristics are associated with repeat emergency department (ED) visitation within 30 days of ED discharge for patients presenting with abdominal pain. Methods: A retrospective, observational study was conducted at a single, academic, urban ED with over 85,000 annual visits. A consecutive sample of adult patients with a chief complaint of abdominal pain from January 2010 through December 2010 who were discharged following ED evaluation were included in the analysis. A logistic regression model was used to determine which patient-level factors, including computed tomography (CT) utilization, were associated with the primary outcome of ED revisit within 30 days. Results: Of 80,619 total ED patient visits during the study period, 3,928 ED discharges with a chief complaint of abdominal pain were included. A total of 487 (12.4%) patients revisited the ED within 30 days. No deaths were recorded. CT imaging was associated with a lower 30-day revisit rate (odds ratio [OR] = 0.69, 95% confidence interval [CI] = 0.55 to 0.87) after controlling for multiple other patient-level factors associated with revisits. Increasing age (OR = 1.01, 95% CI = 1.00 to 1.02), increasing triage pain scores (OR = 1.13, 95% CI = 1.08 to 1.18), elevated triage heart rate (OR = 1.42, 95% CI = 1.07 to 1.89), low sodium levels (OR = 1.56, 95% CI = 1.07 to 2.23), and anemia (OR = 1.42, 95% CI = 1.04 to 1.95) were all associated with increased rate of return. Conclusions: Performance of an abdominal CT was associated with fewer 30-day revisits, suggesting that future measures of "imaging appropriateness" and "ED overuse" consider downstream utilization of health care resources in addition to the index visit. ACADEMIC EMERGENCY MEDICINE 2015;22:803-810 A growing number of patients present to the emergency department (ED) for complex and efficient diagnostic evaluation. 1 As such, the use of advanced imaging in the ED has increased, with computed tomography (CT) utilization increasing 330% in the United States from 1996 to 2007. 2 ED visits and use of imaging, however, are commonly viewed as inefficient or overused, with numerous publications focus-ing on reducing "unnecessary" ED visits or "unnecessary" CT scans. 3,4 As Americans increasingly rely on the ED for acute, unscheduled care, 5 increased scrutiny on return visits to the ED as a measure of lower quality and more costly care has emerged. 6 Current data suggest that 22% of all ED discharges gener

Increased Computed Tomography Utilization in the Emergency Department and Its Association with Hospital Admission

“…The news media, policymakers, patients, and healthcare providers have called CT utilization into question 23 , 36 , 37 because diagnostic imaging is considered one of the key drivers of increasing healthcare cost in the U.S. 38 One study reported that use of abdominal CT was associated with decreased revisits, 39 but other studies have suggested that outcomes are not necessarily improved with more imaging. 40 – 44 The prevalence of over-testing, over-diagnosing, and over-treating has been criticized in modern medicine.…”

Overtesting and the Downstream Consequences of Overtreatment: Implications of “Preventing Overdiagnosis” for Emergency Medicine

“…There are also measurable benefits of advanced imaging. For example, utilizing CTs for some ED conditions is also associated with lower ED returns, and CT use has been associated with lower negative appendectomy rates . Measuring and rewarding diagnostic efficiency might incentivize more rational test ordering, but defining “diagnostic efficiency” is an unmet challenge.…”

Epidemiology and outcomes of acute abdominal pain in a large urban Emergency Department: retrospective analysis of 5,340 cases

“…Despite substantial improvement in the diagnostic approach to AAP, mainly attributable to the extensive use of imaging techniques [especially computed tomography (CT)], many diagnostic pitfalls remain, which can be associated with a substantial number of misdiagnoses and/or avoidable surgery (6)(7)(8). The differential diagnosis of AAP in the adult population is rather broad, including appendicitis, peptic ulcer, urinary stones, inflammatory bowel disease, hepatobiliary diseases (e.g., biliary colic, cholecystitis, and pancreatitis), referred pain due to pneumonia as well as several other "mimics" of extra-abdominal origin (9)(10)(11).…”