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CT Scans, Criticized for Downsides, Also Are Beneficial for ED Diagnosis

BOSTON – With all of the concerns about the costs and risks of using CT scans in the emergency department, some of the benefits might be overlooked, according to a new study finding those benefits to be substantial.

The report, published online recently by the journal Radiology, finds that, after viewing CT scan results, physicians in the EDs of four major academic medical centers made key changes in clinical decision-making for patients with common presentations.

Researchers from the Massachusetts General Hospital (MGH) Institute for Technology Assessment suggest their results add critical information to health policy debates about the appropriate use of CT scanning.

"Emergency department physicians who face increasing pressure to make clinical decisions quickly are sometimes criticized for ordering too many CT scans that may not be clinically justified," explained lead author Pari Pandharipande, MD, MPH, director of the MGH Institute of Technology Assessment. "We found that – for patients with abdominal pain, chest pain or shortness of breath, or with headache - physicians' leading diagnoses and management decisions frequently changed after CT and that diagnostic uncertainty felt by physicians was alleviated."

Use of CT scanning has more than tripled in EDs over the past 20 years, but the benefits of increasing those procedures have not been clear, leading to complaints about over-reliance on imaging despite costs and increased radiation exposure for patients.

For the study, conducted between July 2012 and January 2014, ED physicians, both staff and residents, were asked to complete brief surveys after their initial evaluation of patients with abdominal pain, chest pain/shortness of breath, or headache. They then were asked to complete a new survey after receiving CT scan results.

While pre-CT surveys queried respondents about an initial diagnosis, the clinician’s confidence in that diagnosis, any alternative diagnoses that should be ruled out and current management decisions, post-CT surveys asked whether the initial diagnosis had changed, whether the CT scan had helped to confirm or rule out alternative diagnoses, and whether management decisions had changed.

With 245 physicians completing both surveys for 1,280 patients, diagnoses changed for 51% of patients with abdominal pain, 42% of patients with chest pain/shortness of breath and 24% of patients with headache.

In addition, the scans changed decisions about whether patients required hospital admission in 116 of 457 patients with abdominal pain (25%), 72 of 387 with chest pain and/or dyspnea (19%), and 81 of 426 with headache (19%).

"While there was a wide spectrum of diagnostic confidence before CT, the greater a physician's initial confidence in a diagnosis, the less likely that diagnosis was to change after CT, indicating that physicians were sound judges of their own diagnostic certainty,” Pandharipande, also an assistant professor of radiology at Harvard Medical School, said in an MGH press release. “But even in instances where physicians' pre-CT confidence in their initial diagnosis was greater than 90%, there were still changes in from 4% to 21% of cases.”

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