80% of requests for emergency head CT inadequate, single-center study finds
Nearly 80% of referrer requests for emergency head CTs are inadequate, according to the results of a single-center study published Tuesday.
Utilization of this critical modality has risen approximately 30% since 2007, one April analysis found. For one Italian emergency department, CT referrals have leapt more than twofold since 2008, leading to both rising healthcare costs and escalating ionizing radiation exposure, experts write in Insights into Imaging.
Researchers with a public hospital in Trento, Italy, aimed to assess the adequacy of CT requests over a four-month period in 2022. They found only about 21% of such requisitions were appropriate, signaling clear need for reform.
“Excessive head CT requests in the ED cause needless radiation, pollution, and costs,” Dr. Carlo Cosimo Quattrocchi, a radiologist and researcher with the University of Trento, and co-authors advised. “Integrating guidelines and prospective justification with clear documentation in patient records, along with improved staff training and a no-blame culture, are key to reducing unnecessary imaging.”
The study sample included over 2,900 head CT requests logged between January and April at one emergency department. Researchers assessed each referral’s quality using the previously proposed Reason for Exam Imaging Reporting and Data System (RI-RADS). Dr. Quattrocchi and co-authors further assessed referral appropriateness using quality criteria from the American College of Radiology.
They found only about one-fifth (or about 620) of head CT requests were adequate in terms of quality while the other 79% (or 2,288) were not. For about 400 of the cases, it was not possible to evaluate appropriateness according to ACR guidelines, due to the lack of clinical data. However, among the other roughly 2,500 referrals, 25% were deemed “usually not appropriate” in terms of clinical indication.
Of those head imaging requests deemed “adequate” (RI-RADS category A or B), about 84% were also appropriate. That’s compared to about 70% for those deemed inappropriate using the scoring system (RI-RADS category C or D). Among all patients with inappropriate requests, about 98% did not suffer from acute cerebral diseases based on imaging, with headache and syncope the primary clinical indications. Analysis of positivity rates revealed a significant difference between appropriate and inappropriate CT scan requests (at 11% vs. 1%).
“The risk of inappropriate head CT scans could be mitigated by improving the quality of requests, as suggested by the lower number of appropriate requests scored as RI-RADS C or D,” the authors reported. “This can be attributed to the difficulty emergency physicians face in applying guidelines without a clear diagnostic query. Furthermore, defensive medicine, which is widespread but especially prevalent in emergency settings, plays a significant role, with CTs often requested under the false assumption of improved legal standing.”
Read more, including potential study limitations, in Insights Into Imaging here.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.