Rationale and Objectives
The increasing use of imaging in the emergency department (ED) services has become an important problem on the basis of cost and unnecessary exposure to radiation. Radiographic examination of the chest has been reported to be performed in 34.4% of ED visits, and chest computerized tomography (CCT) in 15.8%, whereas some patients receive both chest radiography and CCT in the same visit. In the current study, it was aimed to establish instances of medical waste and unnecessary radiation exposure and to show how the inclusion of radiologists in the ordering process would affect the amount of unnecessary imaging studies.
Materials and Methods
This retrospective study included 1012 ED patients who had both chest radiography and CCT during the same visit at Ankara Training and Research Hospital between April 2015 and January 2016. The patients were divided into subgroups of trauma and nontrauma. To detect unnecessary imaging examinations, data were analyzed according to the presence of additional findings on CCT images and the recommendation of a radiologist for CCT imaging.
Results
In the trauma group, 77.1% (461/598) and in the nontrauma group, 80.4% (334/414) of patients could be treated without any need for CCT. In the trauma group, the radiologist recommendation only, and in the nontrauma group, both the radiologist recommendation and the age were determined to be able to predict the risk of having additional findings on CCT.
Conclusions
Considering only the age of the patient before ordering CCT could decrease the rate of unnecessary imaging. Including radiologists into both the evaluation and the ordering processes may help to save resources and decrease exposure to ionizing radiation.
Introduction
From the beginning of the 20th century, imaging has been a rapidly growing field of physician services . Imaging studies are primarily performed in hospital outpatient facilities, private offices, hospital inpatient facilities, and emergency departments (ED) . The increasing use of imaging in ED services has attracted the attention of a significant number of researchers. Various studies have suggested that this increase, especially in cases of computerized tomography (CT), has higher costs but has not provided improved outcomes .
The number of ED visits has also increased from 123.8 million in 2008 to 136.3 million in 2011. It has been reported that radiographic examination of the chest is performed in 34.4% of ED visits, and a chest computerized tomography (CCT) in 15.8% of visits . Chest radiography (CXR) is applied at the ED visits of more than 70% of patients with acute cardiothoracic symptoms, CCT for the same indication in more than 13% of cases , and some patients receive both CXR and CCT in the same visit.
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Materials and Methods
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Statistical Analysis
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Results
Patients
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TABLE 1
The Distribution of Additional Findings
Additional Findings Number (Percentage) Rib fracture 86(39.6) Consolidation 44(20.3) Contusion 36(16,6) Pleural effusion 36(16,6) Pulmonary embolism 25(11,5) Vertebral fracture 15(6,9) Pneumothorax/Hemothorax 14(6,5) Others(pericardial effusion, mediastinal emphysema, dissection, mass lesions, small airway disease, etc.) 5(2,3) Total 217(21,4)
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Trauma Versus Nontrauma
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Presence of Additional Findings
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Regression Analysis
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TABLE 2
Regression Analysis Results
Variables Univariable Multivariable OR %95C.I.P OR %95C.I.P Lower Upper Lower Upper All population Age 1,160 1,090 1,230 <0,001 \* 1,150 1,070 1,230 <0,001 \* Radiologist recommendation (ref: not recommended) 4,752 3,334 6,774 <0,001 \* 4,145 2,282 7,529 <0,001 \* Sex (ref \\ :female) 1,381 0,996 1,915 0,053 — — — — CXR (ref:normal) 3,000 2,178 4,132 <0,001 \* — — — — Trauma (ref: nontraumatic) 1,241 0,910 1,691 0,172 — — — — Nagelkerke R 2 = 0,253; P < 0,001 \* Trauma group Radiologist recommendation (ref: not recommended) 3,791 2,268 6,336 <0,001 \* 3,772 1,711 8,316 0,001 \* Age 1,120 1,010 1,230 0,046 — — — — Sex (ref:female) 1,506 0,903 2,512 0,117 — — — — CXR (ref:normal) 2,381 1,448 3,915 0,001 \* — — — — Nagelkerke R 2 = 0,197; P < 0,001 \* Nontrauma group Age 1,240 1,140 1,340 <0,001 \* 1,180 1,080 1,290 <0,001 \* Radiologist recommendation (ref: not recommended) 9,417 5,281 16,792 <0,001 \* 4,490 1,753 11,500 0,002 \* Sex (ref:female) 1,249 0,813 1,917 0,310 — — — — CXR (ref:normal) 6,348 3,859 10,443 <0,001 \* — — — — Nagelkerke R 2 = 0,285; P < 0,001 \*
CXR, chest radiography; OR, odds ratio; 95% C.I., 95% confidence interval.
Stepwise backward method was used in multivariable regression models.
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Discussion
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Conclusion
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