Emergency Department Computed Tomography Utilization in the United States and Canada

Berdahl, Carl T.; Vermeulen, Marian J.; Larson, David B.; Schull, Michael J.

doi:10.1016/j.annemergmed.2013.02.018

Cited by 145 publications

(97 citation statements)

References 21 publications

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“…This is lower than American numbers during the same time period (22.8% in 2005 and 37.4% in 2009), 2 consistent with a previous study that found that CT imaging in Canada was lower than in the US for patients with abdominal pain, headache, chest pain, or shortness of breath. 18 These numbers are despite recommendations by several professional groups that CT imaging not be used for the diagnosis of brain stem or cerebellar strokes, 10,11,17 the types of strokes that cause vertigo. Our results support this recommendation: patients who received CT imaging and were discharged from an ED in Ontario with a diagnosis of peripheral vertigo had a significantly higher frequency of early strokes than matched patients who did not receive CT imaging, suggesting a missed event in the ED.…”

Section: Discussionmentioning

confidence: 99%

“…2 Numbers in the other countries are unknown although CT imaging for other clinical indications is lower in Canada than in the US. 18 In addition to increased radiation exposure, which is associated with increased risk for certain cancers, 19 the use of a potentially insensitive, low-yield test could result in false reassurance for the managing physician, and paradoxically leave the patient with an undetected, untreated, central cause of vertigo. The purpose of this study was to determine how many patients discharged from a Canadian ED with a diagnosis of peripheral vertigo received head CT imaging during their evaluation, and to compare subsequent early strokes between patients who received CT imaging during their ED visit with matched patients who did not, to assess whether cerebellum and brain stem strokes were being missed.…”

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confidence: 99%

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Missed Strokes Using Computed Tomography Imaging in Patients With Vertigo

Grewal

Austin

Kapral

et al. 2015

Stroke

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Background and Purpose-The purpose of this study was to determine the proportion of emergency department (ED) patients with a diagnosis of peripheral vertigo who received computed tomography (CT) head imaging in the ED and to examine whether strokes were missed using CT imaging. Methods-This population-based retrospective cohort study assessed patients who were discharged from an ED in Ontario, Canada, with a diagnosis of peripheral vertigo, April 2006 to March 2011. Patients who received CT imaging (exposed) were matched by propensity score methods to patients who did not (unexposed). If performed, CT imaging was presumed to be negative for stroke because brain stem/cerebellar stroke would result in hospitalization. We compared the incidence of stroke within 30, 90, and 365 days subsequent to ED discharge between groups, to determine whether the exposed group had a higher frequency of early strokes than the matched unexposed group. Results-Among 41 794 qualifying patients, 8596 (20.6%) received ED head CT imaging, and 99.8% of these patients were able to be matched to a control. Among exposed patients, 25 (0.29%) were hospitalized for stroke within 30 days when compared with 11 (0.13%) among matched nonexposed patients. The relative risk of a 30-and 90-day stroke among exposed versus unexposed patients was 2.27 (95% confidence interval, 1.12-4.62) and 1.94 (95% confidence interval, 1.10-3.43), respectively. There was no difference between groups at 1 year. Strokes occurred at a median of 32.0 days (interquartile range, 4.0-33.0 days) in exposed patients, compared with 105 days (interquartile range, 11.5-204.5) in unexposed patients. Conclusions-One fifth of patients diagnosed with peripheral vertigo in Ontario received imaging that is not recommended in guidelines, and that imaging was associated with missed strokes.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Missed Strokes Using Computed Tomography Imaging in Patients With Vertigo

Grewal

Austin

Kapral

et al. 2015

Stroke

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“…National patient samples indicate that approximately 16.5 to 64 million patients visit EDs annually for chest pain or shortness of breath. 3,44 Moreover, qPTP might have cumulative cost reductions for patients who return for similar symptoms that are medically unexplained. 45 In the predicate trial of ED patients with chest pain and dyspnea, an astounding 31% returned to an ED within 90 days of enrollment, most for similar symptoms, without a tangible medical cause.…”

Section: Discussionmentioning

confidence: 99%

Cost‐effectiveness of Quantitative Pretest Probability Intended to Reduce Unnecessary Medical Radiation Exposure in Emergency Department Patients With Chest Pain and Dyspnea

Troyer

Jones

Shapiro

et al. 2015

Academic Emergency Medicine

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Objectives: Quantitative pretest probability (qPTP) incorporated into a decision support tool with advice can reduce unnecessary diagnostic testing among patients with symptoms suggestive of acute coronary syndrome (ACS) and pulmonary embolism (PE), reducing 30-day costs without an increase in 90-day adverse outcomes. This study estimates long-term (beyond 90-day) costs and outcomes associated with qPTP. The authors hypothesized that qPTP reduces lifetime costs and improves outcomes in low-risk patients with symptoms suggestive of ACS and PE.Methods: This was a cost-effectiveness analysis of a multicenter, randomized controlled trial of adult emergency patients with dyspnea and chest pain, in which a clinician encountering a low-risk patient with symptoms suggestive of ACS or PE conducted either the intervention (qPTP for ACS and PE with advice) or the sham (no qPTP and no advice). Effect of the intervention over a patient's lifetime was assessed using a Markov microsimulation model. Short-term costs and outcomes were from the trial; long-term outcomes and costs were from the literature. Outcomes included lifetime transition to PE, ACS, and intracranial hemorrhage (ICH); mortality from cancer, ICH, PE, ACS, renal failure, and ischemic stroke; quality-adjusted life-years (QALYs); and total medical costs compared between simulated intervention and sham groups.Results: Markov microsimulation for a 40-year-old patient receiving qPTP found lifetime cost savings of $497 for women and $528 for men, associated with small gains in QALYs (2 and 6 days, respectively) and lower rates of cancer mortality in both sexes, but a reduction in ICH only in males. Sensitivity analysis for patients aged 60 years predicted that qPTP would continue to save costs and also reduce mortality from both ICH and cancer. Use of qPTP significantly reduced the lifetime probability of PE diagnosis, with lower probability of death from PE in both sexes aged 40 to 60 years. However, use of qPTP reduced the rate of ACS diagnosis and death from ACS at age 40, but increased the death rate from ACS at age 60 for both sexes.

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“…ciTBI was defined as previously described to include intubation duration greater than 24 hours, total hospital LOS greater than 48 hours, need for a neurosurgical procedure, and/or death. 1 QuickBrain MRI has been used routinely at our institution to perform follow-up imaging in all pediatric patients with TBI during their hospitalization. In addition, a number of pediatric patients with spinal cord conditions can undergo qbMRI for evaluation but in fact have no intracranial lesion; therefore, they represent a population with negative head-imaging results.…”

Section: Methodsmentioning

confidence: 99%

QuickBrain MRI for the detection of acute pediatric traumatic brain injury

Sheridan

Newgard

Selden

et al. 2017

PED

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OBJECTIVE The current gold-standard imaging modality for pediatric traumatic brain injury (TBI) is CT, but it confers risks associated with ionizing radiation. QuickBrain MRI (qbMRI) is a rapid brain MRI protocol that has been studied in the setting of hydrocephalus, but its ability to detect traumatic injuries is unknown. METHODS The authors performed a retrospective cohort study of pediatric patients with TBI who were undergoing evaluation at a single Level I trauma center between February 2010 and December 2013. Patients who underwent CT imaging of the head and qbMRI during their acute hospitalization were included. Images were reviewed independently by 2 neuroradiology fellows blinded to patient identifiers. Image review consisted of identifying traumatic mass lesions and their intracranial compartment and the presence or absence of midline shift. CT imaging was used as the reference against which qbMRI was measured. RESULTS A total of 54 patients met the inclusion criteria; the median patient age was 3.24 years, 65% were male, and 74% were noted to have a Glasgow Coma Scale score of 14 or greater. The sensitivity and specificity of qbMRI to detect any lesion were 85% (95% CI 73%–93%) and 100% (95% CI 61%–100%), respectively; the sensitivity increased to 100% (95% CI 89%–100%) for clinically important TBIs as previously defined. The mean interval between CT and qbMRI was 27.5 hours, and approximately half of the images were obtained within 12 hours. CONCLUSIONS In this retrospective pilot study, qbMRI demonstrated reasonable sensitivity and specificity for detecting a lesion or injury seen with neuroimaging (radiographic TBI) and clinically important acute pediatric TBI.

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Emergency Department Computed Tomography Utilization in the United States and Canada

Cited by 145 publications

References 21 publications

Missed Strokes Using Computed Tomography Imaging in Patients With Vertigo

Missed Strokes Using Computed Tomography Imaging in Patients With Vertigo

Cost‐effectiveness of Quantitative Pretest Probability Intended to Reduce Unnecessary Medical Radiation Exposure in Emergency Department Patients With Chest Pain and Dyspnea

QuickBrain MRI for the detection of acute pediatric traumatic brain injury

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