Determinants of Computed Tomography Head Scan Ordering for Patients with Low-Risk Headache in the Emergency Department

Abstract

BackgroundMany specialty societies have found that neuroimaging in headache is a low-value intervention for benign presentations. This study describes factors that influence Emergency Room (ER) physicians’ adherence to Choosing Wisely (CW) recommendations for low-risk headache patients presenting to Calgary’s Emergency Departments (EDs). Emergency medicine has yet to address imaging in headache as a CW topic; however, this study may inform that decision.MethodsData were retrospectively collected for all patients presenting to Calgary EDs with headaches from April 1, 2014 to March 31, 2016. Patients were deemed low-risk by virtue of discharge home from the ED, age < 50, and no lumbar puncture (LP), trauma, neurology, or neurosurgery consult or red flags on history. The primary outcome was computed tomography (CT) ordering rates with an eye to medical doctor (MD) practice variation. Patient, physician, and environmental factors were analyzed to compare patients who did and did not receive a CT.ResultsTwo thousand seven hundred and thirty-four headache patients met the eligibility criteria. A total of 117 Calgary ER physicians were included, all of whom had seen 10 or more headache patients over the study period. Physician practice variation was vast, with a mean ordering rate of 38.0% and a range of 0% to 95% (M = 39.0%, IQR = 21.0%). CTs were ordered more often in males than females (39.9%; 34.1%; p = 0.002) and in patients presenting during the day and evening (38.1%; 39.0%) compared to the night (29.7%; p < 0.001). Patients were divided into quartiles by age, with the oldest group (41.6 - 50 years) receiving significantly more head CTs (45.1%) than the other quartiles (34.9%; 34.9%; 27.5%; p < 0.001). Longer triage-to-discharge times were associated with an increase in CT ordering rates (12% for < 2.95 hours; 35% for > 4 hour wait; p < 0.001). Lastly, patients who did not have a CT were more likely to revisit the ED within seven days compared to those who did (6.9% vs 4.0%; p = 0.003), but their seven-day admission rate was unaffected (0.6% in the group that got CTs and 0.3% in the group that did not get a CT). Time to assessment, the day of the week, physician gender, years of experience, and training program did not influence CT ordering practices.ConclusionTo our knowledge, this is the first study to assess how patient, physician, and environmental factors relate to the use of CT scans in low-risk headaches presenting to the ED. CW guidelines are not optimally adhered to, and the findings in this study findings may inspire new ideas for maximizing the judicious use of healthcare resources.

Is Head Computerized Tomography Indicated for the Workup of Headache in Patients with Intact Neurological Examination

“…The risk for developing cancer following a single head CT scan is low [1]. In addition, patients who underwent CT scan on their first visit to the ED were significantly less likely to have subsequent visits [10][11][12]. Our results clearly indicate that a normal neurologic examination by a neurologist cannot exclude significant causes for secondary headache with possible therapeutic consequences.…”

“…Others added more factors, such as physical aggravation (during exertion, with coughing, with sneezing, related to sexual activity, or with Valsalva maneuver), systemic symptoms (fever, weight loss, coughing), and recent history of head or neck injury [9]. In summary, there is substantial practice variation among physicians and significant inconsistency in guiding the ED physician as to what is the best neuroimaging approach for headaches [10].…”

Low-value care practice in headache: a Spanish mixed methods research study

“…There are also other possible factors that modify the compliment with "Do not Do" recommendations. Our study doesn't approached other causes related to sociodemographic and personal characteristics of patient and provider as they have been discussed in other studies [32].…”

A Systematic Review Protocol to Determine the Most Effective Strategies to Reduce Computed Tomography Usage in the Emergency Department

“…Some of these CTs are likely avoidable. As an example, one study looking at low-risk headaches suggested that more than 38% of patients may be imaged unnecessarily [4]. If the increasing use of CT was associated with improved patient-oriented outcomes, the risks may be worth the benefits but that is not always the case.…”