Ordering of computed tomography scans for head and cervical spine: a qualitative study exploring influences on doctors’ decision-making

Abstract

Background Ordering of computed tomography (CT) scans needs to consideration of diagnostic utility as well as resource utilisation and radiation exposure. Several factors influence ordering decisions, including evidence-based clinical decision support tools to rule out serious disease. The aim of this qualitative study was to explore factors influencing Emergency Department (ED) doctors’ decisions to order CT of the head or cervical spine. Methods In-depth semi-structured interviews were conducted with purposively selected ED doctors from two affiliated public hospitals. An interview tool with 10 questions, including three hypothetical scenarios, was developed and validated to guide discussions. Interviews were audio recorded, transcribed verbatim, and compared with field notes. Transcribed data were imported into NVivo Release 1.3 to facilitate coding and thematic analysis. Results In total 21 doctors participated in semi-structured interviews between February and December 2020; mean interview duration was 35 min. Data saturation was reached. Participants ranged from first-year interns to experienced consultants. Five overarching emerging themes were: 1) health system and local context, 2) work structure and support, 3) professional practices and responsibility, 4) reliable patient information, and 5) holistic patient-centred care. Mapping of themes and sub-themes against a behaviour change model provided a basis for future interventions. Conclusions CT ordering is complex and multifaceted. Multiple factors are considered by ED doctors during decisions to order CT scans for head or c-spine injuries. Increased education on the use of clinical decision support tools and an overall strategy to improve awareness of low-value care is needed. Strategies to reduce low-yield CT ordering will need to be sustainable, sophisticated and supportive to achieve lasting change.

Understanding the factors that influence CT utilization for mild traumatic brain injury in a low resource setting - a qualitative study using the Theoretical Domains Framework

“…Previous studies indicate several clinical- and nonclinical-interconnected factors influence emergency physicians' decision-making when ordering CTS for mTBI [ 25 , 26 ]. In the process of health care quality improvement, theoretical understanding of the factors involved in changing the behaviors of healthcare providers (HCPs) is important in the initial stages [27] .…”

Inappropriate computed tomography examinations among children and young adults in a limited resource setting: A cross-sectional retrospective study

“…It is, therefore, crucial to prioritize appropriate and evidence-based use of CT scans in resource-constrained settings to mitigate these consequences and ensure optimal healthcare delivery. Previous studies have cited the utilization of CT scans to be influenced by multiple, complex clinical and non-clinical interrelated factors involving various aspects of healthcare infrastructure, socio-economic conditions, and healthcare provider capabilities [21][22][23] . The International Basic Safety Standards for Protection Against Risks associated with exposure to ionizing radiation recommends measuring the appropriateness of imaging requisitions against evidence-based guidelines or use /medical records for clinical audits [24] .…”