Inconsistencies in EPs’ Ordering of Head CTs

There is significant variation in emergency physicians’ ordering of head CT scans for trauma patients, according to a survey of 37 attending EPs conducted during 2009, which quantified their risk tolerance and malpractice fear.1

“What this shows is that despite guidelines and best practices, physicians are highly variable in the way they utilize imaging. It certainly begs the question of what is required to decrease the variability,” says Richard D. Zane, MD, FAAEM, one of the study’s authors and chair of the Department of Emergency Medicine at University of Colorado Hospital in Denver.

“Standards and best practices are widely published; they are just not followed,” says Zane. “It’s unclear why, but we do know that practice patterns suggest that physicians are not following standard practices for utilization of imaging.”

Tools Decrease Variation

Zane says that variability in EPs’ ordering of head CT scans can be decreased by embedding decision support tools in electronic medical records and order entry systems, and standardizing guidelines and practices, not only within one ED and hospital but within systems, regions, and even the United States.

“There are so many guidelines that it’s impossible to remember every single indication for every study,” he says. “Embedded decision supports allows real-time access to those guidelines in a very specific way.”

Depending on how the tool is set up, if the EP ordered a diagnostic intervention without meeting the criteria within the guidelines, it would either allow the EP to move forward, ask the EP to enter the reason before moving forward, or not allow the EP to move forward.

“We have had tremendous success with embedded decision supports for ordering chest CTs for PE [pulmonary embolism],” reports Zane.2

Variability was decreased after EPs were asked for an explanation if they ordered a CT for PE that didn’t meet certain criteria, and given reminders if patients recently had a chest X-ray.

Zane attributes this to a combination of real-time education and the fact that EPs knew their ordering was being watched and that if they were aberrant, their reason would be looked at. “Also, they are somehow being assuaged by the fact that the institution is endorsing the guidelines because they are embedded in the ordering system,” he says.

A 2011 survey of 245 members of the Michigan College of Emergency Physicians showed that EPs with a higher fear of malpractice score tended to order more head CT scans in pediatric minor head trauma.3

“Despite this trend, our group was surprised that this association was not statistically significant,” adds Andrew Wong, MD, the study’s lead author and associate medical director in the Department of Emergency Medicine at University of California, Irvine Medical Center.

How malpractice risk factors into medical decision-making may be different for other medical conditions, says Wong, noting that other research links malpractice fear with ED decision-making in evaluating patients with possible acute cardiac ischemia.4

“You never know why a physician perceives risk,” says Zane. “In fact, what people have seen is that there is no single attributable factor that has a physician feeling as though this is a risky encounter.” What is unclear is whether the EPs’ perception of risk is actually grounded, he adds.

“In general, what prompts patients to sue doctors or hospitals are issues revolving around the doctor-patient relationship,” says Wong.5

Wong says that the decision to perform a head CT on an ED trauma patient should be based on the clinical context, and not malpractice risk. “There are guidelines, such as the Canadian Head CT Rule, created to help clinicians make those decisions,” he notes.

However, malpractice concerns may play into an EP’s decision if he or she is put in a situation in which a head CT is not clinically indicated, but the patient or family persists in demanding a head CT. “In this case, the doctor-patient relationship is adversarial, and if an adverse event were to occur, the patient is more likely to sue.” he explains. “Under this circumstance, I can see how a physician is inclined to order a head CT.”

References

1. Andruchow JE, Raja AS, Prevedello LM, et al. Variation in head computed tomography use for emergency department trauma patients and physician risk tolerance. Arch Intern Med. 2012;172(8):660-661.

2. Raja AS, Ip IK, Prevedello LM, et al. Effect of computerized clinical decision support on the use and yield of CT pulmonary angiography in the emergency department. Radiology 2011;262(2):468-474.

3. Wong AC, Kowalenko T, Roahen-Harrison S, et al. A survey of emergency physicians’ fear of malpractice and its association with the decision to order computed tomography scans for children with minor head trauma. Pediatr Emerg Care. 2011;27(3):182-185.

4. Katz DA, Williams GC, Brown RL, et al. Emergency physicians’ fear of malpractice in evaluating patients with possible acute cardiac ischemia. Ann Emerg Med. 2005;46(6):525-533.

5. Beckman HB, et al. The doctor-patient relationship and malpractice lessons from plaintiff depositions. Arch Intern Med. 1994;154(12):1365-1370.

Sources

For more information, contact:

  • Andrew Wong, MD, Assistant Clinical Professor of Emergency Medicine/Associate Medical Director, Department of Emergency Medicine, University of California, Irvine School of Medicine. Phone: (714) 456-5239. E-mail: andrew.wong@uci.edu.
  • Richard D. Zane, MD, FAAEM, Chair, Department of Emergency Medicine, University of Colorado Hospital, Denver. E-mail: richard.zane@ucdenver.edu.