Rationale and Objectives
We evaluated the effects of a streamlined emergency department (ED) policy for CT ordering, pre- and postimplementation, on the completed imaging study rates of all after-hours computed tomography (CT) studies. The study hypothesis was that a streamlined CT ordering process would increase the utilization rates of ED CT.
Materials and Methods
A prospective cohort study was used to estimate the effect of enhancing a preauthorization policy for after-hours CT studies requested through the ED, performed between January 1 and June 30, 2013, and the postimplementation period, performed between January 1 and June 30, 2014. Inclusion criteria were all CT chest, CT abdomen/pelvis, musculoskeletal, neurological, and neuroangiographic examinations performed by ED physicians on adult patients. Pre- and postintervention examination imaging study rates were compared.
Results
The period following implementation of the preauthorization policy was associated with a statistically significant increase in utilization for most subtypes of CT examinations (CT chest, CT abdomen/pelvis, and musculoskeletal CT studies), with the exception of neurological examinations, which showed a significant decrease.
Conclusions
This study demonstrates a trend toward increased utilization of CT resources after implementation of an ED preauthorization policy with most study types showing significantly increased utilization. In the case of neurological examinations, a potential “substitution effect” was observed, whereby the rates of neuroangiographic studies showed a marked increase, offsetting the decrease in general neurological examinations performed. Departments considering implementation of preauthorization policies should weigh carefully the benefits of ED workflow efficiencies against the potential harms of increased CT use.
Background
Numerous North American healthcare system stakeholders have expressed concern about emergency department (ED) overutilization of imaging studies, particularly computed tomography (CT) imaging. A number of hypotheses have been raised as to the factors that may lead to overutilization including incorporation of a CT scanner within an ED . Inappropriate imaging use may be associated with rising costs of health care as well as increased lifetime risk of cancer, and it has been suggested by several authors that increased imaging resource use may not lead to improved patient outcomes . Results of certain studies have suggested that, given considerable ED inter-physician variability in the use of specific CT study types, a standardized approach to ordering CT studies is recommended, ideally including a straightforward policy for ED physicians during the imaging examination order process .
Our center created a streamlined CT examination ordering policy that was implemented in the belief that it would improve ease of CT ordering to decrease ED patient turnaround times. The hypothesis is that a streamlined ordering process for all commonly requested CT ED studies should decrease the length of stay for ED patients who require one of those CT examinations included within the policy. Other centers have experimented with the implementation of ED decision support systems in an effort to decrease the use of unnecessary imaging with either equivocal or mixed results when there were fewer limitations placed on imaging resource availability .
Study Objective
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Methods
Study Design, Data Collection, Setting, and Participants
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Table 1
Imaging Study Subtypes Included Within Each CT Examination Category
Study Category Study Subtypes Included Neuroimaging \* CT head with or without contrast, CT carotid arteries, CT circle of Willis, CT facial bones with and without contrast, CT spine, CT orbits, and CT paranasal sinuses Neuroangiography CT carotids and CT circle of Willis angiogram Thorax, abdomen, pelvis \\ CT pulmonary embolism, CT chest/abdomen/pelvis with or without contrast, CT chest with or without contrast, and CT pelvis with contrast Thorax, abdomen, pelvis angiography CT arterial angiogram, abdominal angiograms, thoracic angiograms, and arterial runoff examinations (including upper and lower extremities) Musculoskeletal imaging CT any joint and CT bony pelvis
CT, computed tomography.
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Statistical Methods
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Results
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Table 2
Volume of Examinations Requested During the Pre- and Postauthorization Periods
Period_P_ Value 2013 2014 Examination TAP 1770 (45.5) 2120 (54.5) <0.001 TAP angiography 503 (46.4) 582 (53.6) Neurotrauma 4049 (54.2) 3426 (45.8) Neuroangiography 252 (38.6) 401 (61.4) MSK 179 (45.4) 215 (54.6)
MSK, musculoskeletal; TAP, thorax/abdomen/pelvis.
Table 3
Proportion of Examinations Ordered in the Postauthorization Policy Period
Period 2014 95% CI Examination TAP 2120 (54.5) 52.9–56.1 TAP angiography 582 (53.6) 50.6–56.6 Neurological 3426 (45.8) 44.7–47.0 Neuroangiography 401 (61.4) 57.6–65.2 MSK 215 (54.6) 49.5–59.6
CI, confidence interval; MSK, musculoskeletal; TAP, thorax/abdomen/pelvis.
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Discussion
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Conclusion
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