24 Jan CT alters management, cuts hospital admissions in the ED

AuntMinnie.com | CT not only improves the management of abdominal pain patients in the emergency department (ED), it also reduces hospital admissions significantly while boosting diagnostic confidence, according to a new study published in the February edition of the American Journal of Roentgenology.

Researchers from Massachusetts General Hospital in Boston found that the use of CT for abdominal complaints cut admissions by 44% and changed physicians’ initial diagnosis in 49% of patients, while increasing diagnostic confidence by 31%.

Despite concerns over the ionizing radiation delivered in CT exams, the modality has been shown to improve diagnosis and management of patients in the emergency department, although most previous studies have been retrospective in nature, wrote Hani Abujudeh, MD, and colleagues (AJR, February 2011, Vol. 196, pp. 238-243).

Of the 115 million visits to the emergency department in 2005, 7.8 million patients (6.8%) reported stomach and abdominal pain as their chief complaint, according to the authors.

“Abdominal pain presents diagnostic challenges in all demographic populations,” they wrote. “In addition to defining the correct diagnosis, emergency physicians also face the challenge of correctly managing patients in a timely fashion by deciding whether patients need to undergo surgery, require hospital admission for further workup, or can be safely discharged from the hospital.”

The prospective study aimed to determine how CT affects physicians’ diagnostic certainty and management decisions in patients with nontraumatic abdominal complaints presenting to the emergency department.

Physical exam time in the emergency department is short and patient histories are often incomplete, so imaging examinations have proved useful. But given the concerns about radiation dose, it’s important to know whether CT helps patient management in a significant way, the authors wrote.

The group evaluated 584 patients (mean age, 53.5 years; range, 18-94) who presented with nontraumatic abdominal complaints to the emergency department from November 2006 through February 2008.

Prospective surveys of ED clinicians were conducted both before and after abdominal CT to determine the leading diagnosis, diagnostic certainty, and management decisions. Changes between the before and after surveys were assessed by Fisher’s exact test and the log likelihood ratio. According to the results:

• The most common diagnoses at CT were renal colic (119/584, 20.4%) and intestinal obstruction (80/584, 13.7%).
• CT changed the leading diagnosis in 49% of the patients (284/584, p < 0.00001).
• CT increased mean physician diagnostic certainty from 70.5% (before CT) to 92.2% (post-CT) (p < 0.001; log likelihood ratio, 2.48).
• The use of CT also changed patient management in 42% of patients (244/583, p < 0.0001).

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