Self-awareness of computed tomography ordering in the emergency department

Kadhim-Saleh, Amjed; Worrall, J.; Taljaard, Monica; Gatien, Mathieu; Perry, Jeffrey J.

doi:10.1017/cem.2017.45

Cited by 11 publications

(8 citation statements)

References 35 publications

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“…Although this study did not specifically focus on why cross-sectional imaging was used in our cohort, reasons that have been found for its overutilization in general include knowledge deficit, fear of missing a diagnosis, anxiety about medico-legal risk, and concerns about patient satisfaction [ 22 , 23 ]. Gastroenterologists are not often consulted on patients with mild, acute pancreatitis and practitioners who treat them may not be familiar with guideline-based indications for cross-sectional imaging in these patients.…”

Section: Discussionmentioning

confidence: 99%

The utility of early cross-sectional imaging to evaluate suspected acute mild pancreatitis

Reynolds

Brady

Chawla

2018

aog

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BackgroundThere are roughly 300,000 hospitalizations for acute pancreatitis annually in the United States. Many of the affected patients at our institution undergo computed tomography (CT) or magnetic resonance imaging (MRI) unnecessarily early during their admissions. We hypothesize that cross-sectional imaging within 48 h of admission in patients meeting the criteria for acute, mild pancreatitis is over-utilized and does not change management.MethodsWe performed a retrospective analysis of patients with a discharge diagnosis of acute pancreatitis from our tertiary care institution from January 1, 2010 to December 31, 2015. Inclusion criteria were a lipase more than three times the upper limit of normal and clinical suspicion of pancreatitis. Exclusion criteria were an etiology of pancreatitis following endoscopic retrograde cholangiopancreatography, recurrent or chronic pancreatitis, severe pancreatitis, and ultrasound findings being the reason for imaging.ResultsOf the 166 patients who met the criteria for analysis, 105 (63.3%) underwent cross-sectional imaging within 48 h of presentation (CT: 104, MRI: 1). Of the examined CTs, 27 (26.0%) showed no abnormality and 55 (52.9%) revealed uncomplicated pancreatitis. The remaining 22 (21.2%) demonstrated at least one of the following: local complications, biliary ductal dilatation or other findings. On thorough chart review, only two patients received a beneficial change in management as a result of the early imaging.ConclusionsThis analysis supports current guidelines that early cross-sectional abdominal imaging (CT or MRI) in patients with suspected acute mild pancreatitis does not alter medical management. Early imaging may lead to unnecessary resource use and patient irradiation.

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Section: Discussionmentioning

confidence: 99%

The utility of early cross-sectional imaging to evaluate suspected acute mild pancreatitis

Reynolds

Brady

Chawla

2018

aog

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“…Our investigation uncovered relatively poor physician self-awareness of CT ordering behavior, with only 20% of physicians accurately assessing their practice and most physicians overestimating their own CT ordering rate. Based on a previous study of CT ordering self-estimates, we had expected physicians to underestimate their CT ordering frequency [ 11 ]. We had expected our A&F intervention to work by demonstrating that underestimation to physicians, thereby enhancing their self-awareness of actual ordering behavior, and prompting them to reduce ordering.…”

Section: Discussionmentioning

confidence: 99%

“…In recent years, it has come to light that ED physicians may lack self-awareness of their own CT utilization behaviors [ 11 ], which could be contributing to the observed variability in ordering practices. Given the poor self-awareness reported to occur in ED-based CT ordering, audit and feedback (A&F) may be an effective implementation strategy to improve physicians’ CT ordering behavior.…”

Section: Introductionmentioning

confidence: 99%

“…Perceiving potential similarities with EM opioid prescribing and EM CT utilization (over-prescribing and over-ordering, respectively) as well as potential similarities in limited self-awareness in both EM opioid prescribing and CT utilization [ 11 , 16 ], we postulated that a similar implementation strategy as reported by Michael et al for opioid prescribing may similarly result in CT utilization reduction. Therefore, in the same study setting and with a similar methodology as the aforementioned opioid investigation, we undertook an A&F investigation related to ED CT utilization.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Accuracy of emergency physicians’ self-estimates of CT scan utilization and its potential effect on an audit and feedback intervention: a randomized trial

Larkin

Sanseverino

Joseph

et al. 2021

Implement Sci Commun

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Background Audit and feedback (A&F) has been used as a strategy to modify clinician behavior with moderate success. Although A&F is theorized to work by improving the accuracy of clinicians’ estimates of their own behavior, few interventions have included assessment of clinicians’ estimates at baseline to examine whether they account for intervention success or failure. We tested an A&F intervention to reduce computed tomography (CT) ordering by emergency physicians, while also examining the physicians’ baseline estimates of their own behavior compared to peers. Methods Our study was a prospective, multi-site, 20-month, randomized trial to examine the effect of an A&F intervention on CT ordering rates, overall and by test subtype. From the electronic health record, we obtained 12 months of baseline CT ordering per 100 patients treated for every physician from four emergency departments. Those who were randomized to receive A&F were shown a de-identified graph of the group’s baseline CT utilization, asked to estimate wherein the distribution of their own CT order practices fell, and then shown their actual performance. All participants also received a brief educational intervention. CT ordering rates were collected for all physicians for 6 months after the intervention. Pre-post ordering rates were compared using independent and repeated measures t tests. Results Fifty-one of 52 eligible physicians participated. The mean CT ordering rate increased significantly in both experimental conditions after the intervention (intervention pre = 35.7, post = 40.3, t = 4.13, p < 0.001; control pre = 33.9, post = 38.9, t = 3.94, p = 0.001), with no significant between-group difference observed at follow-up (t = 0.43, p = 0.67). Within the intervention group, physicians had poor accuracy in estimating their own ordering behavior at baseline: most overestimated and all guessed that they were in the upper half of the distribution of their peers. CT ordering increased regardless of self-estimate accuracy. Conclusions Our A&F intervention failed to reduce physician CT ordering: our feedback to the physicians showed most of them that they had overestimated their CT ordering behavior, and they were therefore unlikely to reduce it as a result. After “audit,” it may be prudent to assess baseline clinician awareness of behavior before moving toward a feedback intervention.

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“…Epidemiological studies have highlighted that even two to three CT scans lead to a significant increase in the risk of cancer, especially in children (3). Physicians' defensive medicine approaches, the risk of not missing a diagnosis, medical-legal risk, contrast risk and patient requests may have been effective (4). Nevertheless, CT continues to be the decisive factor because it increases diagnostic accuracy in potential patient management (5,6).…”

Section: Introductionmentioning

confidence: 99%

Investigation of radiological and clinical features of brain computed tomography findings of patients in the emergency department

Yavaş

Alpaslan

2020

Bozok Tıp Dergisi

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Çalışmamızın amacı klinik tanı ile uyumlu acil servise giriş yapan hastaların çektikleri beyin bilgisayarlı tomografisi sonuçlarını göstermektir. Gereç ve Yöntemler: Bu çalışma, acil servisten 1 Ocak 2018 ile 30 Haziran 2018 tarihleri arasında bilgisayarlı tomografi taraması geçirmiş, yaş ve cinsiyet arasında bir ayrım gözetmeyen tüm hastaları içermektedir. Hastalar acil servise baş ağrısı, baş dönmesi, trafik kazası ve serebrovasküler olay (SVO) gibi şikayetleri ile kabul edildi. Hastaların yaş, cinsiyetleri ve beyin tomografi bulgularının sayı ve yüzde bulguları analiz edildi. Bulgular: Toplam altı ayda, 16428 hastanın 3975'inin beyin BT görüntüsü vardı. Çalışmamızda erkek hasta 2018 (% 51), kadın hasta 1957 (% 49) ve yaş ortalaması 45,40 ± 24 idi. Baş ağrısı, baş dönmesi, travma ve SVO şikayeti ile acilden radyolojiye sevk edilen hastalar dahil edildi. Çalışmada, rapor bulgularının 735'si (% 19) anlamlıydı ve 3240 (% 81) hastada önemsizdi. Sonuç: Rapor bulgularının büyük ölçüde temiz olması, bu kadar çok BT görüntüsünün neden yapıldığı sorusunu ortaya koymaktadır.

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Self-awareness of computed tomography ordering in the emergency department

Cited by 11 publications

References 35 publications

The utility of early cross-sectional imaging to evaluate suspected acute mild pancreatitis

The utility of early cross-sectional imaging to evaluate suspected acute mild pancreatitis

Accuracy of emergency physicians’ self-estimates of CT scan utilization and its potential effect on an audit and feedback intervention: a randomized trial

Investigation of radiological and clinical features of brain computed tomography findings of patients in the emergency department

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