As worrisome as radiation from CT scans is, the dramatic increase in the use of this imaging technology over12 years has averted costly admissions and patient transfers, according to a report this week in the Annals of Emergency Medicine.
Researchers in Michigan, Atlanta and New Haven looked at data from the National Hospital Medical Care Survey, a database of ED services in the United States and found that CT use increased during ED visits from 3.2% to 13.9% between 1996 and 2007.
ED visits increased about 30% over this period, "whereas CT use increased 330%, meaning the rate of CT use increased to 11 times the ED visit rate," they wrote. "And by 2007, approximately one in seven patients with an ED visit underwent a CT scan as part of their evaluation."
These increases were pegged to a variety of complaints, but the greatest percentages were seen in older patients and in those presenting with abdominal pain, flank pain, chest pain, and shortness of breath.
But by the end of the study period, the adjusted rate of hospitalization or transfer after a scan decreased from 26% in 1996 to 12.1% in 2007, or by about half.
The rate has diminished and leveled off since 2003, wrote lead author Keith Kocher, MD, of the University of Michigan in Ann Arbor, and colleagues. Admissions to an intensive care unit, among the most expensive levels of care in a hospital, declined as well.
The researchers did not provide estimates of how much was saved in healthcare costs or bed days avoided.
CT imaging in the ED accounts for 25% of all CT scanning in the country, they found.
The authors recommend several next steps. For starters, they want more research to link particular patient complaints with the ED provider's choice to call for a CT. They also want more effort to better delineate where use of CT results in better resource utilization and clinical outcomes.
But in an accompanying editorial, Robert Wears, MD, of the University of Florida Health Science Center, questions whether ED physicians are using CT scans too much, simply to be more certain of a diagnosis or to satisfy patients' demands that everything possible be done.
Wears's piece is entitled "The Hunting of the Snark," after the Lewis Carroll work about a group that pursues a mythic creature but meets its own doom in the process. "One is struck by the feeling that, in our quest for ever more perfect certainty, we are reenacting that famous tragedy."
"If physicians observe that many of their colleagues are using CT more liberally, it begins to seem at least okay and eventually may persuade them to join the crowd because, after all, the 'standard of care' is that which most physicians do," Wears wrote.
He added, "It seems inevitable that any good tool will be overused at some point; in fact, that is how we learn where the boundaries of diminishing returns are."
In a comment about the article and editorial, president of the American College of Emergency Physicians Sandra Schneider, MD, said a CT scan is great at diagnostics. It can, for example, identify patients with appendicitis accurately, "saving unnecessary exploratory operations or admitting the patient for observation."
"However, the improved certainty saves money and pain, but has a cost – increased radiation.
"Sometimes we order it to protect ourselves from a possible malpractice suit," for example even when prior screening is 98% accurate, she wrote.
"If we provided reasonable protection for emergency physicians who follow endorsed guidelines (perhaps with compensation for that one in a thousand victim) then we might see some real cost reduction in healthcare."
See Also:
CT, MRI Use in Emergency Departments Soaring
High-Dose Radiation Imaging Guidelines Inadequate, Researchers Say
Radiation Patients Endanger Public, Congressman Says