Use of CT Scans for Abdominal Pain in the ED: Factors in Choice

Mwinyogle, Aubrey; Bhatt, Astha; Ogbuagu, Onyebuchi U; Dhillon, Neer; Sill, Anne; Kowdley, Gopal C.

doi:10.1177/000313482008600428

Cited by 14 publications

(7 citation statements)

References 19 publications

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“…Despite CT scan resulting in the correct clinical diagnosis up to 87% of the time of patients with non-traumatic abdominal pain in the emergency department, 38 it is currently utilized for only about 54% of patients presenting with these symptoms. 39 Increase utilization of CT scan in patients with abdominal pain and relevant risk factors could be 1 way to decrease the incidence of missed AAA and aortic dissections in the emergency department. As reflected with a higher prevalence of "other CV misdiagnosis" for aortic dissections, initial misdiagnosis of acute myocardial infarction in patients with dissections also remains a concern.…”

Section: Discussionmentioning

confidence: 99%

Review of Malpractice Lawsuits in the Diagnosis and Management of Aortic Aneurysms and Aortic Dissections

Choinski

Sanon

Tadros

et al. 2021

Vasc Endovascular Surg

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Objective: Aortic aneurysms and dissections are prevalent causes of morbidity and mortality. The management of aortic pathologies may be called into question in malpractice suits. Malpractice claims were analyzed to understand common reasons for litigation, medical specialties involved, patient injuries, and outcomes. Methods: Litigation cases in the Westlaw database from September 1st, 1987 to October 23 rd, 2019 were analyzed. Search terms included “aortic aneurysm” and “aortic dissection.” Data on plaintiff, defendant, litigation claims, patient injuries, misdiagnoses, and case outcomes were collected and compared for aortic aneurysms, aortic dissections, and overall cases. Results: A total of 346 cases were identified, 196 involving aortic aneurysms and 150 aortic dissections. Physician defendants were emergency medicine (29%), cardiology (20%), internal medicine (14%), radiology (11%), cardiothoracic (10%) and vascular surgery (10%). Litigation claims included “failure to diagnose and treat” (61%), “delayed diagnosis and treatment” (21%), “post-operative complications after open repair” (10%) and “negligent post-operative care” (10%). Patients with aneurysms presented with abdominal (63%) and back pain (37%), while dissections presented with chest pain (78%), abdominal pain (15%), and shortness of breath (14%). Misdiagnoses included gastrointestinal (12%), other cardiovascular (9%), and musculoskeletal conditions (9%), but many were not specified (58%). Overall, 83% of cases were wrongful death suits. Injuries included loss of consortium (23%), emotional distress (19%), and bleeding (17%). In 53% of the cases, the jury ruled in favor of the defendant. 25% of cases ruled for the plaintiff. 22% of cases resulted in a settlement. The mean rewarded for each case was $1,644,590.66 (SD: $5,939,134.58; Range: $17,500-$68,035,462). Conclusion: For aortic pathologies, post-operative complications were not prominent among the reasons why suits were brought forth. This suggests improvements in education across all involved medical specialties may allow for improved diagnostic accuracy and efficient treatment, which could then translate to a decrease in associated litigation cases.

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Section: Discussionmentioning

confidence: 99%

Review of Malpractice Lawsuits in the Diagnosis and Management of Aortic Aneurysms and Aortic Dissections

Choinski

Sanon

Tadros

et al. 2021

Vasc Endovascular Surg

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“…Race and ethnicity were not reported in any of our 13 included studies, making assessment of disparities in these domains impossible. Outside of the studies identified by our systematic search, other studies have documented disparities in ED CT imaging based on insurance status, 120 race, and ethnicity 120–122 . Patients with Medicaid are 20% less likely than privately insured patients to undergo CTAP for acute abdominal pain (not specifically recurrent pain or repeat CTAP) 120 .…”

Section: Questionmentioning

confidence: 99%

“…Outside of the studies identified by our systematic search, other studies have documented disparities in ED CT imaging based on insurance status, 120 race, and ethnicity. [120][121][122] Patients with Medicaid are 20% less likely than privately insured patients to undergo CTAP for acute abdominal pain (not specifically recurrent pain or repeat CTAP). 120 Black and Hispanic patients are 42% to 52% less likely than White patients to undergo CTAP for acute abdominal pain.…”

Section: Decision Criteria and Additional Considerationsmentioning

confidence: 99%

“…120 Black and Hispanic patients are 42% to 52% less likely than White patients to undergo CTAP for acute abdominal pain. 120,122 Conclusions and research needs…”

Section: Decision Criteria and Additional Considerationsmentioning

confidence: 99%

“…Patients with Medicaid are 20% less likely than privately insured patients to undergo CTAP for acute abdominal pain (not specifically recurrent pain or repeat CTAP) 120 . Black and Hispanic patients are 42% to 52% less likely than White patients to undergo CTAP for acute abdominal pain 120,122 …”

Section: Questionmentioning

confidence: 99%

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

Broder

Silva

Bellolio

et al. 2022

Academic Emergency Medicine

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This second Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE‐2) from the Society for Academic Emergency Medicine is on the topic “low‐risk, recurrent abdominal pain in the emergency department.” The multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding four priority questions for adult emergency department patients with low‐risk, recurrent, undifferentiated abdominal pain. The intended population includes adults with multiple similar presentations of abdominal signs and symptoms recurring over a period of months or years. The panel reached the following recommendations: (1) if a prior negative computed tomography of the abdomen and pelvis (CTAP) has been performed within 12 months, there is insufficient evidence to accurately identify populations in whom repeat CTAP imaging can be safely avoided or routinely recommended; (2) if CTAP with IV contrast is negative, we suggest against ultrasound unless there is concern for pelvic or biliary pathology; (3) we suggest that screening for depression and/or anxiety may be performed during the ED evaluation; and (4) we suggest an opioid‐minimizing strategy for pain control. EXECUTIVE SUMMARY The GRACE‐2 writing group developed clinically relevant questions to address the care of adult patients with low‐risk, recurrent, previously undifferentiated abdominal pain in the emergency department (ED). Four patient‐intervention‐comparison‐outcome‐time (PICOT) questions were developed by consensus of the writing group, who performed a systematic review of the literature and then synthesized direct and indirect evidence to formulate recommendations, following GRADE methodology. The writing group found that despite the commonality and relevance of these questions in emergency care, the quantity and quality of evidence were very limited, and even fundamental definitions of the population and outcomes of interest are lacking. Future research opportunities include developing precise and clinically relevant definitions of low‐risk, recurrent, undifferentiated abdominal pain and determining the scope of the existing populations in terms of annual national ED visits for this complaint, costs of care, and patient and provider preferences.

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Race and Ethnicity and Diagnostic Testing for Common Conditions in the Acute Care Setting

Ellenbogen,

Weygandt,

Newman-Toker

et al. 2024

JAMA Netw Open

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ImportanceOveruse of diagnostic testing is pervasive, but the extent to which it varies by race and ethnicity in the acute care setting is poorly understood.ObjectiveTo use a previously validated diagnostic intensity index to evaluate differences in diagnostic testing rates by race and ethnicity in the acute care setting, which may serve as a surrogate for diagnostic test overuse.Design, Setting, and ParticipantsThis was a cross-sectional study of emergency department (ED) discharges, hospital observation stays, and hospital admissions using administrative claims among EDs and acute care hospitals in Kentucky, Maryland, North Carolina, and New Jersey, from 2016 through 2018. The diagnostic intensity index pairs nonspecific principal discharge diagnoses (nausea and vomiting, abdominal pain, chest pain, and syncope) with related diagnostic tests to estimate rates of nondiagnostic testing. Adults with an acute care encounter with a principal discharge diagnosis of interest were included. Data were analyzed from January to February 2024.ExposureRace and ethnicity (Asian, Black, Hispanic, White, other [including American Indian, multiracial, and multiethnic], and missing).Main Outcomes and MeasuresReceipt of a diagnostic test. Generalized linear models with a hospital-specific indicator variable were estimated to calculate the adjusted odds ratio of receiving a test related to the principal discharge diagnosis by race and ethnicity, controlling for primary payer and zip code income quartile.ResultsOf 3 683 055 encounters (1 055 575 encounters [28.7%] for Black, 300 333 encounters [8.2%] for Hispanic, and 2 140 335 encounters [58.1%] for White patients; mean [SD] age of patients with encounters, 47.3 [18.8] years; 2 233 024 encounters among females [60.6%]), most (2 969 974 encounters [80.6%]) were ED discharges. Black compared with White patients discharged from the ED with a diagnosis of interest had an adjusted odds ratio of 0.74 (95% CI, 0.72-0.75) of having related diagnostic testing. No other racial or ethnic disparities of a similar magnitude were observed in any acute care settings.Conclusions and RelevanceIn this study, White patients discharged from the ED with a nonspecific diagnosis of interest were significantly more likely than Black patients to receive related diagnostic testing. The extent to which this represents diagnostic test overuse in White patients vs undertesting and missed diagnoses in Black patients deserves further study.

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Use of CT Scans for Abdominal Pain in the ED: Factors in Choice

Cited by 14 publications

References 19 publications

Review of Malpractice Lawsuits in the Diagnosis and Management of Aortic Aneurysms and Aortic Dissections

Review of Malpractice Lawsuits in the Diagnosis and Management of Aortic Aneurysms and Aortic Dissections

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

Race and Ethnicity and Diagnostic Testing for Common Conditions in the Acute Care Setting

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