Most Abdominal CT, Ultrasound Scans in the ED Are Inappropriately Ordered

Every year, thousands of people go to the emergency room, complaining of abdominal pain, and they undergo either a CT scan or ultrasound to figure out what could be wrong. But, according to a new study, a significant number of these studies are ordered inappropriately, leading to additional problems further down the road.

In a study published Nov. 15 in Current Problems in Diagnostic Radiology, investigators from the Federal University of Health Sciences of Porto Alegre in Brazil revealed that 36 percent of CT scans and 84 percent of ultrasounds that were ordered did not comply with the American College of Radiology’s appropriateness criteria.

The problem expanded beyond CTs and ultrasounds, however. In 20 percent of cases, ultrasound images that did not follow appropriateness guidelines led to providers ordering more studies with an additional modality. Not only did that increase costs and utilization, but it also led to patients have longer waits in the emergency department.

To reach this determination, the team, led by Martina Zaguini Francisco, M.D., from Federal University, retrospectively reviewed 135 CT scans and 143 ultrasounds that were ordered in the emergency department for complaints of abdominal pain between January 2019 and March 2019.

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While they found that properly ordered studies were significantly more likely to detect findings that were in line with the provider’s initial perceptions, they also determined there were many reasons why a provider might inappropriately order an exam. Fears of malpractice accounted for a large number of these studies, but a lack of education was also at fault, the team said.

“Although there is wide and ready dissemination of ACR tools, the lack of awareness of existing guidelines remains a major problem,” they said. “This results not only in imaging overuse, but also in wrong modalities being requested, leading to additional imaging orders during the same visit.”

In fact, the team pointed out, more than 85 percent of emergency providers said they know they order too many tests. And, those tests can be considered inappropriate either because they were ordered on the wrong modality, they were not the recommended test of first-use, or the results of the scan will not impact or change any care management.

According to their analysis – and ACR appropriateness criteria – the team found most of the inappropriate CT scans were requested for pancreatitis, renal failure, biliary disease, and uncomplicated pyelonephritis. For ultrasound, most were ordered for diverticulitis, appendicitis, abdominal pain, and uncomplication pyelonephritis.

This study did have a significant limitation, the team said. As a single-center study, they said, it is unlikely their results could be generalizable to other institutions.

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