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Trends in Computed Tomography Utilization and Association with Hospital Outcomes in a Chinese Emergency Department

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      BackgroundExcessive use of computed tomography (CT) in emergency departments (EDs) has become a concern due to its expense and the potential risks associated with radiation exposure. Although studies have shown a steady increase in the number of CT scans requested by ED physicians in developed countries like the United States and Australia, few empirical data are available regarding China.Methods and FindingsWe retrospectively analyzed a database of ED visits to a tertiary Chinese hospital to examine trends in CT utilization and their association with ED outcomes between 2005 and 2008. A total of 197,512 ED visits were included in this study. CT utilization increased from 9.8% in 2005 to 13.9% in 2008 (P<.001 for trend). The ED length of stay for visits with CT utilization was 0.6 hour longer than those in which CT was not obtained. CT utilization increased the ED cost by an average $48.2. After adjustment for patients’ demographics, arrival hours and clinical condition, CT utilization during ED visits was significantly associated with high ED cost (Odds Ratio [OR]: 21.70; 95% confidence interval [CI], 17.00–27.71), long ED length of stay (OR: 1.22; 95%CI, 1.12–1.34), and more likely to receive emergency operations (OR: 2.31; 95%CI, 1.94–2.76). However, there was no significant correlation between CT use and the possibility to be admitted to inpatient wards (OR: 0.82; 95%CI, 0.65–1.04). With respect to the time-related trends, CT utilization during ED visits in all study years was significantly associated with high ED cost and more likely to receive emergency operations.ConclusionCT utilization was associated with higher ED cost, longer ED length of stay and more likely to receive emergency operations, but did not correlate with a significant change in the admission rate.

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      Most cited references 20

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      Computed tomography--an increasing source of radiation exposure.

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        Cancer risks from diagnostic radiology.

        In recent years, there has been a rapid increase in the number of CT scans performed, both in the US and the UK, which has fuelled concern about the long-term consequences of these exposures, particularly in terms of cancer induction. Statistics from the US and the UK indicate a 20-fold and 12-fold increase, respectively, in CT usage over the past two decades, with per caput CT usage in the US being about five times that in the UK. In both countries, most of the collective dose from diagnostic radiology comes from high-dose (in the radiological context) procedures such as CT, interventional radiology and barium enemas; for these procedures, the relevant organ doses are in the range for which there is now direct credible epidemiological evidence of an excess risk of cancer, without the need to extrapolate risks from higher doses. Even for high-dose radiological procedures, the risk to the individual patient is small, so that the benefit/risk balance is generally in the patients' favour. Concerns arise when CT examinations are used without a proven clinical rationale, when alternative modalities could be used with equal efficacy, or when CT scans are repeated unnecessarily. It has been estimated, at least in the US, that these scenarios account for up to one-third of all CT scans. A further issue is the increasing use of CT scans as a screening procedure in asymptomatic patients; at this time, the benefit/risk balance for any of the commonly suggested CT screening techniques has yet to be established.
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          The Canadian CT Head Rule for patients with minor head injury.

          There is much controversy about the use of computed tomography (CT) for patients with minor head injury. We aimed to develop a highly sensitive clinical decision rule for use of CT in patients with minor head injuries. We carried out this prospective cohort study in the emergency departments of ten large Canadian hospitals and included consecutive adults who presented with a Glasgow Coma Scale (GCS) score of 13-15 after head injury. We did standardised clinical assessments before the CT scan. The main outcome measures were need for neurological intervention and clinically important brain injury on CT. The 3121 patients had the following characteristics: mean age 38.7 years); GCS scores of 13 (3.5%), 14 (16.7%), 15 (79.8%); 8% had clinically important brain injury; and 1% required neurological intervention. We derived a CT head rule which consists of five high-risk factors (failure to reach GCS of 15 within 2 h, suspected open skull fracture, any sign of basal skull fracture, vomiting >2 episodes, or age >65 years) and two additional medium-risk factors (amnesia before impact >30 min and dangerous mechanism of injury). The high-risk factors were 100% sensitive (95% CI 92-100%) for predicting need for neurological intervention, and would require only 32% of patients to undergo CT. The medium-risk factors were 98.4% sensitive (95% CI 96-99%) and 49.6% specific for predicting clinically important brain injury, and would require only 54% of patients to undergo CT. We have developed the Canadian CT Head Rule, a highly sensitive decision rule for use of CT. This rule has the potential to significantly standardise and improve the emergency management of patients with minor head injury.

            Author and article information

            [1 ]Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
            [2 ]Department of Biomedical Informatics, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
            [3 ]Department of Epidemiology and Health Statistics, College of Public Health, Zhejiang University, Hangzhou, Zhejiang, China
            [4 ]Vallejo, California, United States of America
            [5 ]Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
            [6 ]Department of Infectious Disease, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
            Yale University School of Medicine, United States of America
            Author notes

            Conceived and designed the experiments: JCZ KR. Performed the experiments: JCZ SWZ CWJ. Analyzed the data: JCZ SWZ YXY KR YSY. Contributed reagents/materials/analysis tools: DYZ KHP YSY. Wrote the paper: JCZ KR. Contributed to the design and interpretation of results: YXY WLJ DYZ KHP YSY.

            Role: Editor
            PLoS One
            PLoS ONE
            PLoS ONE
            Public Library of Science (San Francisco, USA )
            12 July 2012
            : 7
            : 7
            Zhou et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
            Pages: 6
            Research Article
            Radiation Biophysics
            Radiation Exposure
            Clinical Research Design
            Retrospective Studies
            Statistical Methods
            Critical Care and Emergency Medicine
            Non-Clinical Medicine
            Health Care Policy
            Health Risk Analysis
            Health Care Quality
            Public Health
            Occupational and Industrial Health
            Preventive Medicine
            Diagnostic Radiology
            Computed Tomography
            Social and Behavioral Sciences
            Human Capital
            Economics of Health
            Health Economics



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