Emergency Department Computed Tomography Use for Non-traumatic Abdominal Pain: Minimal Variability

Abstract

IntroductionVariability in the use of computed tomography (CT) between providers in the emergency department (ED) suggests that CT is ordered on a provider rather than a patient level. We aimed to evaluate the variability of CT ordering practices for non-traumatic abdominal pain (NTAP) across physicians in the ED using patient-visit and physician-level factors.MethodsWe conducted a retrospective study among 6,409 ED visits for NTAP from January 1 to December 31, 2012, at a large, urban, academic, tertiary-care hospital. We used a two-level hierarchical logistic regression model to estimate inter-physician variation. Intraclass correlation coefficient (ICC) was calculated.ResultsThe hierarchical logistic regression analyses showed that patient-visit factors including younger age, arrival mode by ambulance, prior CT, >79 ED arrivals in the previous four hours, and ultrasound had statistically significant negative associations with physician CT ordering, while surgical team admission and white blood count (WBC) >12.5 K/millimeter cubed (mm3) had statistically significant positive associations with physician CT ordering. With physician-level factors, only physicians with >21 years experience after medical school graduation showed statistical significance negatively associated with physician CT ordering. Our data demonstrated increased CT ordering from the mean in only one out of 43 providers (2.3%), which indicated limited variation across physicians to order CT. After adjusting for patient-visit and physician-level factors, the calculated ICC was 1.46%.ConclusionWe found minimal physician variability in CT ordering practices for NTAP. Patient-visit factors such as age, arrival mode, admission team, prior CT, ED arrivals in previous four hours, ultrasound, and WBC count were found to largely influence CT ordering practices.

Repeat computed tomography in recurrent abdominal pain: An evidence synthesis for guidelines for reasonable and appropriate care in the emergency department

“…The search strategy identified 637 potentially relevant publications. After full‐text review, we found zero studies that provided direct evidence and included 13 studies as indirect evidence 26–38 (Figure 1). These studies were categorized as indirect evidence because none stratify abdominal pain patients into low‐ or non–low‐risk categories, and some include reevaluation of specific pathology identified at the index ED visit, following a positive initial CT, or at an interval less than the 30 days prespecified by the GRACE‐2 expert panel.…”

“…After full-text review, we found zero studies that provided direct evidence and included 13 studies as indirect evidence [26][27][28][29][30][31][32][33][34][35][36][37][38] (Figure 1).…”

Guidelines for Reasonable and Appropriate Care in the Emergency Department 2 (GRACE‐2): Low‐risk, recurrent abdominal pain in the emergency department

“…Thirteen studies met some criteria and were included as indirect evidence . 12,[46][47][48]74,75,[96][97][98][99][100][101][102] We attempted to abstract the a priori defined outcomes of interest (Box 2), but most studies did not provide these. The reviewers identified four alternative outcomes: 95 1.…”

“…Zero studies met all criteria for direct evidence. Thirteen studies met some criteria and were included as indirect evidence 12,46–48,74,75,96–102 …”

“…Predictors of repeat CTAP were reported in some studies. Some investigators 97 found that a prior CTAP (time interval not specified) was associated with a lower probability of undergoing CTAP on a repeat visit (odds ratio [OR] 0.44, 95% CI 0.30 to 0.65). The similarity of previous and current clinical presentations and the risk profile of the patients were not described.…”