Patients who underwent CT exami- nation for atraumatic headache in an initial emergency department
(ED) visit were less likely to return to the
ED within 30 days, according to a paper
titled “The Association Between Use of
Brain CT for Atraumatic Headache and 30-
Day Emergency Department Revisitation”
published in the December 2016 issue of
the American Journal of Roentgenology.
A possible explanation for this finding
is that CT provided reassurance to pa-
tients, thereby preventing return ED vis-
its. Another reason could be that outpatient
providers, particularly primary care clini-
cians, may be able to better focus on and
manage the symptoms of acute head-
ache given the knowledge of negative
CT findings. These are possibilities determined by authors of
the retrospective observational study “The Association Between
Use of Brain C T for Atraumatic Headache and 30-Day Emergency
The study was designed to review the association between
initial C T for atraumatic headache and repeat ED visitation with-
in 30 days of ED discharge.
“I think it would be easy to misinterpret this study as a call for
increasing the practice of ordering C T scans for atraumatic head-
ache,” said study coauthor Brian W. Patterson, assistant profes-
sor, BerbeeWalsh Department of Emergency Medicine,
University of Wisconsin School of Medicine and Public Health,
Madison. “Our findings do not support such a recommenda-
tion. Rather, we are calling attention to the downstream effects of
these scans and suggesting that future attempts to define appro-
priateness of imaging within the ED will need to account for their
potential to lessen future care utilization.”
The authors became interested in the topic amid growing crit-
icism of the overuse of C T imaging in EDs. Many nonemergency
physicians, policymakers, and the press view these procedures
as inefficient or overutilized, and suggest focusing on reducing
“unnecessary” ED visits or imaging studies.
CT for Atraumatic Headache Could
Is It Psychological on the Part of Patients? Or Better Informed Doctors?
Lead to Fewer ED Visits After 30 Days
The issue places emergency care at
the center of two conflicting trends: an increasing scope of practice as a referral
center for outpatient diagnosis and a simultaneous increase in scrutiny of ED imaging and resource utilization. “This
conflict creates a need to evaluate the value added by advanced imaging performed
during ED visits, and to better understand
how imaging use at an initial ED visit influences subsequent resource utilization
and outcomes,” said Patterson.
“We specifically chose to evaluate
head CT for atraumatic headache, as
this is an imaging study that tends to be
fairly low yield when looking at the value
for identifying emergent pathology in
the ED, but anecdotally it is a test that
patients often come in asking for when they have a headache.
We wanted to look at how our decisions in the ED affected downstream care trajectories to try to look at what benefit is provided
by the reassurance of a negative CT scan,” he said.
The study was performed at Northwestern Memorial Hospital,
Chicago, IL, which has more than 85,000 annual visits. Of 80,619
total patient visits to the ED during the study period, 922 ED discharges with a chief complaint of headache were included. A total
of 15.1% (139/922) patients revisited within 30 days, and the return
rate was 11.2% among patients who underwent CT at their initial
visit and 21.1% among those who did not.
Ideally, future studies would be able to capture the effect of
CT on subsequent clinical outcomes and resource use beyond
the confines of a single ED visit. “As the national focus expands
from single visits to episodes of care, we will need an understanding of the role of ED management on subsequent care trajectories,” Patterson said.
In addition to identifying this relationship for policymakers,
the study expands on recent studies showing the ability to feasibly use clinical data obtained from electronic health records to
measure the quality and efficiency of acute care.
“Most important, we were able to measure the efficiency of
imaging use on the basis of the patient’s chief complaint, not the
discharge diagnosis,” Patterson said. “This approach has not
only been recommended by the emergency medicine community, but is also likely a better reflection of the undifferentiated
clinical picture by which patients present to the ED.”n
The study was based on a presentation at the Society for Academic
Emergency Medicine 2013 annual meeting, Dallas, TX.
“As the national focus expands from single
visits to episodes of care, we will need an
understanding of the role of ED management on
subsequent care trajectories.”—Brian W. Patterson