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van Westendorp S, Robben SHM, van Hooft MAA, Dierckx SAA, Maas HAAM. The clinical implications of using a low threshold for computed tomography scans in older patients presenting with a proximal femur fracture. Eur Geriatr Med 2024; 15:1081-1089. [PMID: 38896388 PMCID: PMC11377457 DOI: 10.1007/s41999-024-01007-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 06/10/2024] [Indexed: 06/21/2024]
Abstract
PURPOSE Current guidelines recommend a low threshold for computerized tomography (CT) scanning in older patients presenting with low-energy trauma (LET). With the ageing of the population, this results in increased use of healthcare resources and costs. We aim to assess (1) the number of CT scans performed as part of the initial trauma screening, (2) their traumatic clinical implications, and (3) their non-traumatic clinical implications. METHODS A retrospective study in patients ≥ 70 years presenting at a Dutch trauma centre with a proximal femur fracture following a LET between 2021 and 2022. We collected data concerning demographics, Clinical Frailty Scale, Injury Severity Score, number of CT scans and whether the results of these scans altered clinical management. RESULTS We included 278 patients. Median age was 83.0 years (IQR 77.0-89.0), median ISS was 9 (IQR 9-10) and, most common mechanism of injury was a ground level fall (n = 159, 57.2%). In 49 patients (17.6%) one or more CT scans were performed. These scans did not reveal co-existing traumatic injuries altering clinical management. In 2 patients (0.7%) incidental findings were found that immediately affected treatment. CONCLUSION Our study concludes that (1) approximately one in five patients with a proximal femur fracture received a CT scan as part of the initial trauma screening, resulting in (2) no traumatic and (3) minimal non-traumatic clinical implications. Therefore, a restrictive policy can be justified in patients with no additional clinical signs or symptoms and admission to the hospital. Further prospective research would be valuable to confirm our results.
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Affiliation(s)
- S van Westendorp
- Department of Geriatric Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.
| | - S H M Robben
- Department of Geriatric Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - M A A van Hooft
- Emergency Department, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - S A A Dierckx
- Emergency Department, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - H A A M Maas
- Department of Geriatric Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
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Salastekar NV, Duszak R, Santavicca S, Horný M, Balthazar P, Khaja A, Hughes DR, Hanna TN. Utilization of Chest and Abdominopelvic CT for Traumatic Injury From 2011 to 2018: Evaluation Using a National Commercial Database. AJR Am J Roentgenol 2023; 220:265-271. [PMID: 36000666 DOI: 10.2214/ajr.22.27991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND. Increases in the use of CT to evaluate patients presenting with trauma have raised concern about inappropriate imaging. The evolving utilization of CT for trauma evaluation may be impacted by injury severity. OBJECTIVE. The purpose of this study was to explore patterns in utilization of chest and abdominopelvic CT among trauma-related emergency department (ED) visits across the United States. METHODS. This retrospective study was conducted with national commercial claims information extracted from the MarketScan Commercial Database. Trauma-related ED encounters were identified from the 2011-2018 MarketScan database files and classified by injury severity score (minor, intermediate, and major injuries) on the basis of International Classification of Diseases codes. ED encounters were also assessed for chest CT, abdominopelvic CT, and single-encounter chest and abdominopelvic CT examinations. Utilization per 1000 trauma-related ED encounters was determined. Multivariable Poisson regression models were used to determine incidence rate ratios (IRRs) as a measure of temporal changes in utilization. RESULTS. From 2011 to 2018, 8,369,092 trauma-related ED encounters were identified (5,685,295 for minor, 2,624,944 for intermediate, and 58,853 for major injuries). Utilization of chest CT per 1000 trauma-related ED encounters increased from 4.9 to 13.5 examinations (adjusted IRR, 1.15 per year; minor injuries, from 2.2 to 7.7 [adjusted IRR, 1.17]; intermediate injuries, from 8.5 to 21.5 [adjusted IRR, 1.16]; major injuries, from 117.8 to 200.1 [adjusted IRR, 1.08]). Utilization of abdominopelvic CT per 1000 trauma-related ED encounters increased from 7.5 to 16.4 (adjusted IRR, 1.12; minor injuries, 4.8 to 12.2 [adjusted IRR, 1.13]; intermediate injuries, 10.6 to 21.7 [adjusted IRR, 1.13]; major injuries, 134.8 to 192.6 [adjusted IRR, 1.07]). Utilization of single-encounter chest and abdominopelvic CT per 1000 trauma-related ED encounters increased from 3.4 to 8.9 [adjusted IRR, 1.16; minor injuries, 1.1 to 4.6 [adjusted IRR, 1.18]; intermediate injuries, 6.4 to 16.4 [adjusted IRR, 1.16]; major injuries, 99.6 to 179.9 [adjusted IRR, 1.08]). CONCLUSION. National utilization of chest and abdominopelvic CT for trauma-related ED encounters increased among commercially insured patients from 2011 to 2018, particularly for single-encounter chest and abdominopelvic CT examinations and for minor injuries. CLINICAL IMPACT. Given concerns about increased cost and detection of incidental findings, further investigation is warranted to explore the potential benefit of single-encounter chest and abdominopelvic CT examinations of patients with minor injuries and to develop strategies for optimizing appropriateness of imaging orders.
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Affiliation(s)
- Ninad V Salastekar
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322
| | - Richard Duszak
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322
| | - Stefan Santavicca
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322
| | - Michal Horný
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322
| | - Patricia Balthazar
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322
| | - Akram Khaja
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322
| | - Danny R Hughes
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322
- School of Economics, Georgia Institute of Technology, Atlanta, GA
| | - Tarek N Hanna
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322
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Virji AZ, Cheloff AZ, Ghoshal S, Nagle B, Guo TZ, Lev MH, Raja AS, Gee MS, Succi MD. Analysis of self-initiated visits for cervical trauma at urgent care centers and subsequent emergency department referral. Clin Imaging 2022; 91:14-18. [PMID: 35973271 DOI: 10.1016/j.clinimag.2022.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/20/2022] [Accepted: 08/08/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Following trauma involving the cervical spine (c-spine), patients often seek care at urgent care centers (UCCs) or emergency departments (EDs). PURPOSE The purpose was to assess whether UCCs could effectively image acute self-selected c-spine trauma without referral to the ED as well as to estimate costs differences between UCC and ED imaging assessment. MATERIALS AND METHODS This retrospective study identified patients receiving c-spine imaging at UCCs affiliated with a large academic hospital system from 5/1/-8/31/2021. Patients receiving c-spine X-rays with an indication of trauma following low acuity injury, at UCCs were compared to patients receiving any c-spine imaging in the main campus ED. Medical record numbers were cross-referenced to identify patients receiving imaging at both a UCC and ED within 24 h and within 7 days. Work relative value units (wRVUs) for each UCC and ED imaging type were calculated. For the hypothetical scenario of patients presenting to the ED in the absence of UCC, patients were assumed to receive c-spine computed tomography (CT) without contrast per "usually appropriate" designation by the American College of Radiology Appropriateness Criteria®. RESULTS Among 143 self-selected, low acuity, patients who received c-spine X-rays at UCCs with an indication of trauma, one required referral to the ED within 24 h and two required referrals to the ED within 7 days. During the 4-month study period, 105.94 wRVUs ($3696.25) were saved by performing a c-spine X-ray in an UCC instead of a CT in the ED, extrapolated to 317.82 wRVUs ($11,088.74) per year. Using the average total costs of an UCC visit versus an ED visit, a total $145,976 was estimated to be saved during the study period or $437,928 per year. CONCLUSION Offering access for patient-initiated visits at UCCs for low-acuity c-spine trauma may help reduce the need for an ED visit, reducing imaging and healthcare visit costs. SUMMARY STATEMENT Urgent Care Centers (UCCs) reduced the need for an Emergency Department (ED) referral visit in nearly 100% of self-selected, low acuity, patients with cervical trauma. KEY RESULTS
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Affiliation(s)
- Azan Z Virji
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA, United States
| | - Abraham Z Cheloff
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA, United States
| | - Soham Ghoshal
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA, United States
| | - Baily Nagle
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA, United States
| | - Teddy Z Guo
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA, United States
| | - Michael H Lev
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA, United States
| | - Ali S Raja
- Harvard Medical School, Boston, MA, United States; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Michael S Gee
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA, United States
| | - Marc D Succi
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA, United States.
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