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Trends of CT utilisation in an emergency department in Taiwan: a 5-year retrospective study

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      Abstract

      ObjectivesTo investigate the association between the trends of CT utilisation in an emergency department (ED) and changes in clinical imaging practice and patients' disposition.SettingA hospital-based retrospective observational study of a public 1520-bed referral medical centre in Taiwan.ParticipantsAdult ED visits (aged ≥18 years) during 2009–2013, with or without receiving CT, were enrolled as the study participants.Main outcome measuresFor all enrolled ED visits, we retrospectively analysed: (1) demographic characteristics, (2) triage categories, (3) whether CT was performed and the type of CT scan, (4) further ED disposition, (5) ED cost and (6) ED length of stay.ResultsIn all, 269 239 adult ED visits (148 613 male patients and 120 626 female patients) were collected during the 5-year study period, comprising 38 609 CT scans. CT utilisation increased from 11.10% in 2009 to 17.70% in 2013 (trend test, p<0.001). Four in 5 types of CT scan (head, chest, abdomen and miscellaneous) were increasingly utilised during the study period. Also, CT was increasingly ordered annually in all age groups. Although ED CT utilisation rates increased markedly, the annual ED visits did not actually increase. Moreover, the subsequent admission rate, after receiving ED CT, declined (59.9% in 2009 to 48.2% in 2013).ConclusionsED CT utilisation rates increased significantly during 2009–2013. Emergency physicians may be using CT for non-emergent studies in the ED. Further investigation is needed to determine whether increasing CT utilisation is efficient and cost-effective.

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      Most cited references 27

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      Computed tomography--an increasing source of radiation exposure.

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        Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer.

        Use of computed tomography (CT) for diagnostic evaluation has increased dramatically over the past 2 decades. Even though CT is associated with substantially higher radiation exposure than conventional radiography, typical doses are not known. We sought to estimate the radiation dose associated with common CT studies in clinical practice and quantify the potential cancer risk associated with these examinations. We conducted a retrospective cross-sectional study describing radiation dose associated with the 11 most common types of diagnostic CT studies performed on 1119 consecutive adult patients at 4 San Francisco Bay Area institutions in California between January 1 and May 30, 2008. We estimated lifetime attributable risks of cancer by study type from these measured doses. Radiation doses varied significantly between the different types of CT studies. The overall median effective doses ranged from 2 millisieverts (mSv) for a routine head CT scan to 31 mSv for a multiphase abdomen and pelvis CT scan. Within each type of CT study, effective dose varied significantly within and across institutions, with a mean 13-fold variation between the highest and lowest dose for each study type. The estimated number of CT scans that will lead to the development of a cancer varied widely depending on the specific type of CT examination and the patient's age and sex. An estimated 1 in 270 women who underwent CT coronary angiography at age 40 years will develop cancer from that CT scan (1 in 600 men), compared with an estimated 1 in 8100 women who had a routine head CT scan at the same age (1 in 11 080 men). For 20-year-old patients, the risks were approximately doubled, and for 60-year-old patients, they were approximately 50% lower. Radiation doses from commonly performed diagnostic CT examinations are higher and more variable than generally quoted, highlighting the need for greater standardization across institutions.
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          Projected cancer risks from computed tomographic scans performed in the United States in 2007.

          The use of computed tomographic (CT) scans in the United States (US) has increased more than 3-fold since 1993 to approximately 70 million scans annually. Despite the great medical benefits, there is concern about the potential radiation-related cancer risk. We conducted detailed estimates of the future cancer risks from current CT scan use in the US according to age, sex, and scan type. Risk models based on the National Research Council's "Biological Effects of Ionizing Radiation" report and organ-specific radiation doses derived from a national survey were used to estimate age-specific cancer risks for each scan type. These models were combined with age- and sex-specific scan frequencies for the US in 2007 obtained from survey and insurance claims data. We estimated the mean number of radiation-related incident cancers with 95% uncertainty limits (UL) using Monte Carlo simulations. Overall, we estimated that approximately 29 000 (95% UL, 15 000-45 000) future cancers could be related to CT scans performed in the US in 2007. The largest contributions were from scans of the abdomen and pelvis (n = 14 000) (95% UL, 6900-25 000), chest (n = 4100) (95% UL, 1900-8100), and head (n = 4000) (95% UL, 1100-8700), as well as from chest CT angiography (n = 2700) (95% UL, 1300-5000). One-third of the projected cancers were due to scans performed at the ages of 35 to 54 years compared with 15% due to scans performed at ages younger than 18 years, and 66% were in females. These detailed estimates highlight several areas of CT scan use that make large contributions to the total cancer risk, including several scan types and age groups with a high frequency of use or scans involving relatively high doses, in which risk-reduction efforts may be warranted.
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            Author and article information

            Affiliations
            [1 ]Department of Emergency Medicine, Taichung Veterans General Hospital , Taichung, Taiwan
            [2 ]Department of Medical Research, Center for Translational Medicine, Taichung Veterans General Hospital , Taichung, Taiwan
            [3 ]School of Medicine, Chung Shan Medical University , Taichung, Taiwan
            [4 ]Institute of Medicine, Chung Shan Medical University , Taichung, Taiwan
            [5 ]School of Medicine, National Yang-Ming University , Taipei, Taiwan
            [6 ]Department of Nursing, College of Health, National Taichung University of Science and Technology , Taichung, Taiwan
            [7 ]Department of Nursing, College of Nursing, Central Taiwan University of Science and Technology , Taichung, Taiwan
            [8 ]Department of Emergency Medicine, Taipei Veterans General Hospital, Taoyuan Branch , Taoyuan, Taiwan
            [9 ]Department of Emergency Medicine, Taipei Veterans General Hospital , Taipei, Taiwan
            [10 ]Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health , Taipei, Taiwan
            [11 ]Department of Radiology, Taichung Veterans General Hospital , Taichung, Taiwan
            [12 ]Department of Medical Research, Taichung Veterans General Hospital , Taichung, Taiwan
            [13 ]Department of Critical Care Medicine, Taichung Veterans General Hospital , Taichung, Taiwan
            [14 ]Department of Laboratory Medicine, Da-Jia Lee's General Hospital, Lee's Medical Corporation , Taichung, Taiwan
            [15 ]Department of Laboratory Medicine, Yuan-Li Lee's General Hospital, Lee's Medical Corporation , Miaoli, Taiwan
            [16 ]Medical Technology, Jen-Teh Junior College of Medicine, Nursing and Management , Miaoli, Taiwan
            [17 ]Department of Clinical Laboratory, Drug Testing Center, Chung Shan Medical University Hospital , Taichung, Taiwan
            Author notes
            [Correspondence to ] Professor Yan-Zin Chang; yzc@ 123456csmu.edu.tw
            Journal
            BMJ Open
            BMJ Open
            bmjopen
            bmjopen
            BMJ Open
            BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
            2044-6055
            2016
            8 June 2016
            : 6
            : 6
            27279477
            4908915
            bmjopen-2015-010973
            10.1136/bmjopen-2015-010973
            Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

            This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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