Is CT Imaging Overutilized in the ER?

In a newly published retrospective study looking at the use of computed tomography (CT) in the emergency department (ED) for trauma cases in 2011 and 2018, researchers noted significant increases in the use of chest, abdominopelvic and single-encounter thoraco-abdominopelvic CT orders.

Reviewing data from a national commercial claims database that included 8,369,092 trauma-related visits to the ED, researchers found the use of chest CT more than tripled for minor injuries and there was over a 2.5-fold increase in chest CT use for intermediate injuries, according to the study, published in the American Journal of Roentgenology.¹ For minor injuries, chest CT orders increased from 2.2 per 1,000 trauma-related ED visits in 2011 to 7.7 per 1,000 trauma-related ED visits in 2018. For intermediate injuries, the study authors said chest CT increased from 8.5 per 1,000 ED trauma visits in 2011 to 21.5 per 1,000 ED trauma visits in 2018.¹

The study authors also found the use of abdominopelvic CT more than doubled for minor and intermediate injuries. For minor injuries, the use of abdominopelvic CT increased from 4.8 in 2011 to 12.2 (per 1,000 trauma ED visits) in 2018 for minor injuries and from 10.6 in 2011 to 21.7 (per 1,000 trauma ED visits) in 2018, according to the study.¹

For single-encounter thoraco-abdominopelvic CT, the researchers said use of the exam per 1,000 trauma ED visits quadrupled for minor injuries (1.1 in 2011 to 4.6 in 2018), more than doubled for intermediate trauma injuries (6.4 in 2011 to 16.4 in 2018) and increased from 99.6 (2011) to 179.9 (2018) for major trauma injuries.¹

“The increase in CT utilization per encounter raises concern regarding such imaging’s appropriateness and adherence with practice guidelines,” wrote Tarek N. Hanna, M.D., and colleagues. “In addition, the increase in CT utilization has anticipated associated increases in cost and detection of incidental findings.”

Out of the 8,369,092 ED trauma visits reviewed for the study, 5,685,295 cases (67.9 percent) involved minor injuries.¹ Noting a lack of clarity about the rationale for increased CT use for minor trauma injuries, Hanna and colleagues suggested that a lower baseline utilization of CT for such injuries and a higher level of discomfort among referring physicians with uncertain diagnostic findings may contribute to this issue.

Commenting on the significant increase of single-encounter thoraco-abdominopelvic CT for minor trauma, the study authors speculated that emerging research on the merits of whole-body CT in severe trauma cases may have led to broader application of these principles in minor trauma cases.^2,3

“Further research is warranted to understand the potential benefit of performing CT of multiple body regions, if not of the whole body, in patients with minor trauma, including the impact on clinical decision-making and patient outcomes,” noted Hanna and colleagues.

In regard to study limitations, the authors conceded the use of a claims database of individuals with commercial insurance may prohibit extrapolation of the findings to a general population due to the exclusion of uninsured people and most people eligible for Medicaid or Medicare. Hanna and colleagues also pointed out that the severity of CT findings may have altered or upstaged the initial injury categorization. Due to a lack of direct access to the medical records of those in the study, there was also no assessment of clinical CT reports or whether the CT exams were warranted, according to the study.

References

1. Salastekar N, Duszak Jr R, Santavicca S, et al. Utilization of chest CT and abdominopelvic CT for traumatic injury from 2011 to 2018: evaluation using a national commercial database. AJR Am J Roentgenol. 2022 Aug 24. Doi: 10.2214/AJR.22.27991. Online ahead of print.

2. Sierink JC, Saltzherr TP, Reitsma JB, et al. Systematic review and meta-analysis of immediate total-body computed tomography compared with selective radiological imaging of injured patients. Br J Surg. 2012;99 Suppl 1;52-8.

3. Wurmb TE, Quaisser C, Balling H, et al. Whole-body multislice computed tomography (MSCT) improves trauma care in patients requiring surgery after multiple trauma. Emerg Med J. 2011;28(4):300-4.