Computed Tomography Imaging in the Management of Headache in the Emergency Department: Cost Efficacy and Policy Implications

Jordan, Yusef J.; Lightfoote, Johnson B.; Jordan, John E.

doi:10.1016/s0027-9684(15)30880-4

Cited by 28 publications

(25 citation statements)

References 11 publications

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“…It is definitively more than that identified in another study where it was present in only 8% of patients [13]. Higher rates of sinusitis in our patients could be a result of different classification of minor findings in the nasal sinuses as normal or abnormal between the studies.…”

Section: Discussioncontrasting

confidence: 63%

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

2018

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Introduction: The use of neuroimaging as part of the initial workup in the emergency department (ED) for patients with atraumatic headache is increasing, whereas the proportion of cases in which clinically significant intracranial pathology is detected is decreasing. In the last few decades, the exposure to medical ionized radiation from utilization of computer tomography (CT) increased dramatically, raising concern about radiation-induced cancer. Different guidelines were suggested to address the role of neuroimaging in the investigation of adult patients presenting to the ED with nontraumatic headache. Materials and Methods: We retrospectively evaluated data from all consecutive patients who underwent a head CT in the ED for the evaluation of headache during 2015. Patients were included only if a normal neurologic examination was documented. Results: In total, 422 patients were included. About 43.4% of scans were normal. Most abnormal findings were sinusitis (148 patients, 35%) or ischemic changes. Seven CT scans (1.6%) showed clinically significant findings requiring an immediate change in management. Conclusion: A normal neurologic examination, even when performed by a neurologist, does not rule out a significant secondary cause for headache. A CT scan in the ED is indicated for patients presenting with severe nonremitting headache who never had neuroimaging in the past.

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Section: Discussioncontrasting

confidence: 63%

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

2018

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“…Reducing costs and overutilization of imaging have become an increasing issue as the population ages, and hospitals must manage limited health-care resources. It is well known that ED care is more expensive than outpatient or ambulatory care [2]. Many studies have demonstrated the low yield of imaging evaluation for isolated headache (non-traumatic without specific neurologic findings) [2,4,6,14]; however, most of these studies included outpatients.…”

Section: Discussionmentioning

confidence: 99%

“…Headaches lead to innumerable visits to clinics and emergency rooms around the world. In the setting of non-traumatic headache as an isolated symptom, with no focal neurologic deficits, most patients can be managed safely without radiologic imaging [2]. Multiple previous studies have demonstrated that computed tomography (CT) and magnetic resonance imaging (MRI) evaluation in this patient population is of extremely low yield [2][3][4][5].…”

Section: Introductionmentioning

confidence: 99%

“…In the setting of non-traumatic headache as an isolated symptom, with no focal neurologic deficits, most patients can be managed safely without radiologic imaging [2]. Multiple previous studies have demonstrated that computed tomography (CT) and magnetic resonance imaging (MRI) evaluation in this patient population is of extremely low yield [2][3][4][5]. Unfortunately, emergency physicians often face intense pressure from patients and often feel compelled to obtain imaging, even in those who could be treated conservatively [2].…”

Section: Introductionmentioning

confidence: 99%

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Computed tomography for non-traumatic headache in the emergency department and the impact of follow-up testing on altering the initial diagnosis

et al. 2015

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The purpose of this study was twofold: (1) to determine the incidence of positive computed tomography (CT) findings in patients presenting to the emergency department (ED) with non-traumatic headache at our institution and (2) to examine follow-up exams, including lumbar puncture, non-enhanced CT, CT angiogram, CT venogram, and magnetic resonance imaging (MRI), to see how often the use of further testing changes the diagnosis. With IRB approval, 865 patients were identified through ED requisitions for CT head with the indication of headache during the calendar year 2011. Exclusion criteria included head trauma, prior intracranial surgery, focal neurologic symptoms, and known intracranial mass. CT results were divided into three categories: P0, P1, and P2. Negative studies were graded as P0. Positive studies were subdivided into clinically insignificant or P1 and clinically significant or P2. Clinically significant was defined as requiring medical treatment. Subsequently, the electronic medical records and picture archiving and communication system (PACS) were reviewed to determine the incidence of follow-up exams, including lumbar puncture or imaging. The secondary tests were divided into the same P0, P1, and P2 categories. There were 254 positive studies: P1 clinically insignificant (27.1 %, 235/865) and P2 clinically significant (2.2 %, 19/865). Of 257 follow-up exams performed, the majority were lumbar punctures (36.0 %) or CT angiograms (29.5 %). In 19/257 exams or 7.4 %, the additional testing changed the clinically insignificant (P0/P1) diagnosis to a significant (P2) result. At our institution, there was a 2.2 % incidence of significant positive CT findings in patients presenting to the ED with non-traumatic headache. Follow-up testing was variable and resulted in a 7.4 % increase in the severity of diagnosis compared to the initial negative CT scan.

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“…7,8 This increasing demand for CT studies-in particular for neck and chest evaluations-has been facilitated by the widespread availability of CT scanners and their diagnostic superiority over plain radiography or other modalities. 1,5,6 A number of suggestions have been proposed to explain the rapid observed increase in ED CT utilization at many centres.…”

Section: Discussionmentioning

confidence: 99%

Effect of a preauthorization policy on the utilization rate of after-hours emergency department neuroradiology computed tomography

Dhanoa

Burton

Tilly

et al. 2013

CJEM

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Objective: To evaluate the impact of an emergency department (ED) automatic preauthorization policy on after-hours utilization of neuroradiology computed tomography (CT). Methods: All CT studies of the head with contrast facial bones, orbits, spine, and neck requested through the ED and performed between January 1, 2004, and December 31, 2010, were reviewed. The preauthorization policy was instituted on February 25, 2008. A control group of noncontrast CT head studies was used for comparison. Pre-and postpolicy implementation utilization rates were compared between the control group of noncontrast CT head studies and the study group neuroradiology CT studies. Results: During the study period, 408,501 ED patient visits occurred and 20,703 neuroradiology CT studies were carried out. The pre-and postimplementation groups of noncontrast CT head scans totalled 7,474 and 6,094, respectively, whereas the pre-and postimplementation groups of all other neuroradiology CT studies totalled 3,833 and 3,302, respectively. The CT utilization between the two groups did not differ significantly: the noncontrast head group pre-and postpolicy implementation increased by 0.31 to 3.41%, whereas the utilization of all other neuroradiology CT studies increased by 0.22 to 1.84% (p value 5 0.061 for a difference between groups). Conclusion: Implementation of an automatic preauthorization policy for after-hours neuroradiology CT studies did not result in a statistically significant increase in CT utilization. This suggests that concerns regarding the negative effects of such policies may be unfounded, and further research in this area is warranted. RÉ SUMÉObjectif: L'é tude visait à é valuer l'incidence d'une rè gle d'autorisation pré alable automatique au service des urgences (SU) sur le taux de recours à la tomodensitomé trie (TDM), en neuroradiologie, aprè s les heures normales de travail. Mé thode: Tous les examens de la tê te faits par TDM avec contraste des os de la face, des orbites, de la colonne verté brale, et du cou, demandé s par le SU et effectué s du 1er janvier 2004 au 31 dé cembre 2010 ont é té revus. La rè gle d'autorisation pré alable est entré e en vigueur le 25 fé vrier 2008. Un groupe té moin d'imagerie de la tê te par TDM sans contraste a servi d'ensemble de ré férence. Il y a eu comparaison des taux de recours à la TDM, avant et aprè s l'entré e en vigueur de la rè gle, entre le groupe té moin d'imagerie de la tê te par TDM sans contraste et le groupe à l'é tude d'imagerie par TDM, en neuroradiologie. Ré sultats: Au cours de la pé riode à l'é tude, il y a eu 408,501 consultations au SU, et 20,703 examens ont é té effectué s par TDM, en neuroradiologie. Le nombre total d'examens de la tê te par TDM sans contraste, effectué s dans les groupes avant et aprè s l'entré e en vigueur de la rè gle s'é levait à 7,474 et à 6,094, respectivement, tandis que le nombre total de tous les autres examens faits par TDM, en neuroradiologie, dans les groupes avant et aprè s l'entré e en vigueur de la rè gle s'é levait à 3,833...

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Computed Tomography Imaging in the Management of Headache in the Emergency Department: Cost Efficacy and Policy Implications

Cited by 28 publications

References 11 publications

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

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

Computed tomography for non-traumatic headache in the emergency department and the impact of follow-up testing on altering the initial diagnosis

Effect of a preauthorization policy on the utilization rate of after-hours emergency department neuroradiology computed tomography

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