Emergency Department CT’s Can Change Treatment Decisions

A new study reveals that emergency department (ED) physician diagnoses, diagnostic confidence, and admission decisions change substantially following computerized tomography (CT) scans.

Researchers at Massachusetts General Hospital (MGH; Boston, MA, USA) and other institutions conducted a prospective, four-center study involving 1,280 ED patients with chest pain, abdominal pain, dyspnea, or headache who were referred by 245 physicians to undergo a CT. The physicians were surveyed before and after CT to determine leading and alternative diagnoses, diagnostic confidence, and management decisions. Primary measures were proportion of patients for whom the leading diagnosis or admission decision changed, and median changes in diagnostic confidence.

The results showed that after CT, the physicians' leading diagnoses changed for 51% of patients with abdominal pain, 42% of patients with chest pain and/or shortness of breath, and 24% of patients with headache. The CT scan also helped to confirm or rule out alternative diagnoses in 95%–97% of the cases, across all symptom groups; additionally, decisions regarding patient admission to the hospital changed 19%–25% of the time. The study was published ahead of print on October 10, 2015, in RSNA Radiology.

“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,” said lead author Prof. 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.”

“Our evaluation of physicians' diagnostic confidence revealed compelling results. 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,” added Prof. Pandharipande. “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 percent of cases.”

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