Original Contribution
Variation in use of all types of computed tomography by emergency physicians

https://doi.org/10.1016/j.ajem.2013.07.003Get rights and content

Abstract

Study Objectives

Variation in computed tomography (CT) use between emergency medicine (EM) physicians may delineate appropriate or inappropriate use. We hypothesize that variation in all types of CT use exists between providers and their use in patients with common chief concerns. We determine EM physicians' variability in CT use of all types and whether high use in one area predicts use of other CT types.

Methods

This was a retrospective study of EM physicians practicing at an 800-bed tertiary level 1 trauma center over a 3.5-year period. Computed tomography rates by type and by patient chief concern were modeled for providers as a function of patient acuity, disposition, age, and time of day using logistic regression.

Results

Of 195 801 eligible visits, 44 724 visits resulted in at least 1 CT scan. The adjusted rate of CT ordering by providers was 23.8% of patient visits, ranging from 11.5% to 32.7% The upper quartile of providers was responsible for 78% of the CT scans ordered above the mean. There was a large variation in use of all types of CT and by chief concern. There was an 8-fold variation in use of CT abdomen in discharged patients. High head CT use by providers predicts high use in all other CT types.

Conclusion

We demonstrate a dramatic variation in CT use among EM physicians in all types of CT and common chief concerns. Greater variation was present in patients who were discharged. Large deviation from the mean by a group of providers may suggest inappropriate use.

Introduction

National and emergency department (ED) level data show that computed tomography (CT) use rates have continued to rise in ED care [1], [2], [3], [4], [5], [6], [7], [8]. Some of the increase in CT use can be attributed to increased diagnostic value and subsequent changes in standard of care, although no unified explanation exists for this dramatic increase [9], [10], [11], [12], [13], [14]. Coinciding with the rise in CT use, advanced medical imaging has been identified as a major driver of increasing medical costs [15]. Increased patient exposure to harmful radiation with CT use is also well documented [16], [17], [18], [19], [20]. Reducing head CT use is a current goal of the Centers for Medicare and Medicaid Services [21], [22].

Evidence of variation in head CT use by EDs is also accumulating [23], [24], [25], [26]. A recent study suggests that there is significant interphysician variation of head CT ordering by emergency medicine (EM) physicians that may explain this variation [27]. Risk aversion appears to play some role in provider's excess use of some types of CT [28], [29], [30], although a more recent study suggests that malpractice fear and risk tolerance do not explain such variation [23]. Provider experience also does not appear to impact head CT ordering [27].

Emergency medicine physician variability in use of all CT types has yet to be evaluated. Providers' use may vary in one type of CT imaging and not others. Detailed examination of the variation of all CT ordering may more directly identify physicians that overuse CT imaging in the ED and could direct efforts of reducing inappropriate CT use. We examine whether interphysician variation in CT use exists among providers for all types of CT scans and for common chief concerns and determine if high use of one type of CT imaging can predict use of other types of CT.

Section snippets

Study design

Our study was a retrospective cross-sectional study conducted between August 2008 and January 2012 of EM physicians and ED patients at an 800-bed regional referral teaching hospital and level 1 trauma center. The 70-bed ED is staffed only by board-certified or board-eligible EM physicians and receives 86 000 annual visits. There are 2 helical CT scanners available in the ED. During the study period, only interns (postgraduate year 1 residents) from many different specialties rotated in the

Results

Over the 3.5-year period, 44 724 (22.8%) of the 195 801 unique eligible ED visits resulted in at least 1 CT study, with a total CT study count of 57 282. Of the unique visits, 8220 (18.4%) had multiple CT studies performed during the same visit and 2499 (5.6%) of the 44 724 visits resulted in at least 3 CT studies. The average practice time since the completion of residency was 10.9 years, ranging from 1 to 31 years, with an interquartile range of 3.6 to 15.8 years. Mean number of hours worked

Discussion

We demonstrate that there is a wide variation in all types of CT ordering among EM physicians. This finding persisted despite adjusting for patient level factors that affect CT ordering. There is an even greater variation among providers use of CT in common chief concerns, with a smaller group of providers accounting for a large portion of ED CT use. Their behavior in one modality of CT predicts high use in other areas. It is notable that the bulk of this high rate appears to be explained in

Conclusions

Quality and cost reduction initiatives surrounding CT use must attempt to reduce variation rather than simply focusing on overall rates of use. Decision support systems appear to have some impact on reducing CT use [40]. However, failure to consider or understand potential drivers of high use such as risk aversion, crowding, or throughput pressure may not allow such technology to be fully realized. There are many providers with high CT use, and variation is heavily centered on patients who are

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    A small portion of the work was presented at the American College of Emergency Physicians Scientific Assembly; Denver, CO; October 10, 2012. http://www.annemergmed.com/article/S0196-0644(12)00951-1/fulltext.

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