Early repeat computed tomographic imaging in transferred trauma and neurosurgical patients: Incidence, indications and impact

Factors driving CT utilisation in tertiary hospitals: a decomposition analysis using linked administrative data in Western Australia

OBJECTIVES

While CT scanning plays a significant role in healthcare, its increasing use has raised concerns about inappropriate use. This study investigated factors driving the changing use of CT among people admitted to tertiary hospitals in Western Australia (WA).

DESIGN AND SETTING

A repeated cross-sectional study of CT use in WA in 2003-2005 and 2013-2015 using linked administrative heath data at the individual patient level.

PARTICIPANTS

A total of 2 375 787 tertiary hospital admissions of people aged 18 years or older.

MAIN OUTCOME MEASURE

Rate of CT scanning per 1000 hospital admissions.

METHODS

A multivariable decomposition model was used to quantify the contribution of changes in patient characteristics and changes in the probability of having a CT over the study period.

RESULTS

The rate of CT scanning increased by 112 CT scans per 1000 admissions over the study period. Changes in the distribution of the observed patient characteristics were accounted for 62.7% of the growth in CT use. However, among unplanned admissions, changes in the distribution of patient characteristics only explained 17% of the growth in CT use, the remainder being explained by changes in the probability of having a CT scan. While the relative probability of having a CT scan generally increased over time across most observed characteristics, it reduced in young adults (-2.8%), people living in the rural/remote areas (-0.8%) and people transferred from secondary hospitals (-0.8%).

CONCLUSIONS

Our study highlights potential improvements in practice towards reducing medical radiation exposure in certain high risk population. Since changes in the relative probability of having a CT scan (representing changes in scope) rather than changes in the distribution of the patient characteristics (representing changes in need) explained a major proportion of the growth in CT use, this warrants more in-depth investigations in clinical practices to better inform health policies promoting appropriate use of diagnostic imaging tests.

The Financial and Radiation Burden of Early Reimaging in Neurosurgical Patients: An Original Study and Review of the Literature

The computed tomographic (CT) scanner has become ubiquitous in healthcare. When trauma patients are imaged at facilities not equipped to care for them, imaging is often repeated at the receiving institution. CTs have clinical, financial, and resource costs, and eliminating unnecessary imaging will benefit patients, providers, and institutions. This paper reviews patterns of repetition of CT scans for transferred trauma patients and motivations underlying such behaviors via analysis of our Trauma Registry database and literature published in this area. Neurosurgeons are fundamentally impactful in this decision-making process. The most commonly repeated scan is a CT head (CTH). More than ¼ of our patients receiving a clinically indicated repeat CTH also had a repeat scan of their cervical spine with no reason given for the cervical scan. Herein, we discuss our findings that both non-trauma center practitioners and non-neurosurgical staff at trauma centers cite a lower level of comfort with neuroradiology and fear of litigation as motivators in overzealous neuroimaging. As a result, inappropriate neurosurgical imaging is routinely ordered prior to transfer and again upon arrival at trauma centers. Education of non-neurosurgical staff is essential to prevent inappropriate neuroaxis imaging.

Evaluating our progress with trauma transfer imaging: repeat CT scans, incomplete imaging, and delayed definitive care

PURPOSE

Many trauma patients present at non-trauma centers and require transfer. CT imaging obtained at the initial hospital (IH) may lead to delays in definitive trauma care, and previous studies have shown imaging is often repeated at the trauma center (TC).

METHODS

A retrospective review was performed of all tier 1 trauma patients transferred to our TC between May 2018 and April 2019. Patients that did and did not undergo CT imaging at the IH were compared (n = 147). Of those with IH CT imaging (n = 68), we identified 4 imaging "inadequacies": (1) repeat CT scans: CT scan of the same body region performed at IH and at TC; (2) C-spine inadequacies: severely injured patients who underwent head CT without a C-spine CT; (3) incomplete chest-abdomen-pelvis (CAP): patients with partial CAP CT imaging at IH that underwent an additional portion of CAP imaging at TC; (4) CAP CT without IV contrast.

RESULTS

IH time was significantly prolonged when CT imaging was obtained. Of those that had IH imaging, 13 patients (19%) required repeat CT, ten (15%) had a C-spine inadequacy, 11 (16%) had incomplete CAP, and 28 (41%) had one or more inadequacy. Patients with any inadequacy underwent more CT imaging. Most patients (76%) with imaging at the IH returned to the CT scan at the TC.

CONCLUSION

In severely injured trauma patients transferred to our TC, we identified many continuing issues with IH CT imaging. The imaging inadequacies detailed above lead to delays in definitive care and subject patients to increased radiation.