The authors of a new study found that the majority of emergency referral requests for computed tomography (CT) scans lack sufficient clinical reasoning to justify the CT.
For the retrospective study, recently published in Insights into Imaging, researchers evaluated data from 1,291 cases that involved emergency CT referrals. Utilizing the reason for exam imaging reporting and data system (RI-RADS), the study authors assigned RI-RADS grades of A (adequate), B (barely adequate), C (considerably limited information), D (deficient) and X (no information).
The researchers found that 287 of the 1,291 emergency CT referrals (22.2 percent) had a RI-RADS grade A for adequate quality and 71 cases (5.5 percent) were deemed to have barely adequate quality for a RI-RADS grade B.
In addition to 53 RI-RADS grade D CT referrals (4.1 percent) of deficient quality and 29 RI-RADS grade X cases (2.2 percent) with no information, the study authors said the majority of emergency CT referrals (851 cases or 65.9 percent) had considerably limited information to support the imaging request.
“Our study found that the majority of emergency CT requisitions were inadequate, and potentially reflected worse clinical reasoning quality,” wrote lead study author Xianwei Liu, M.D., who is affiliated with the Department of Imaging at Tongren Hospital and the Shanghai Jiao Tong University School of Medicine in Shanghai, China, and colleagues.
While 97 percent of the reviewed CT requisition forms included the initial impression, the study authors pointed out that 69 percent included clinical information for the patient and only 29 percent indicated the diagnostic question which the referring clinicians were seeking to answer with the CT exam.
The multivariable analysis revealed that emergency CT referrals from neurologists were over 3.5-times more likely to be associated with adequate quality whereas referrals from chest pain centers and fever clinics were 57 percent and 68 percent less likely, respectively, to have adequate information.
Three Key Takeaways
- Prevailing lack of clinical data justification for emergency CT requests. The majority of emergency CT referrals (nearly 66 percent) provided considerably limited clinical information, indicating widespread deficiencies in clinical reasoning and justification for imaging requests.
- The impact of specialty on emergency CT referrals. Referrals from neurologists were over 3.5 times more likely to include adequate information, while those from chest pain and fever clinics were significantly less likely to meet adequacy standards.
- Emphasizing training to bolster quality with CT referral requests. The study underscores the need for targeted training to improve the quality of CT requisitions and ensure imaging requests are guided by clear, clinically reasoned diagnostic questions.
In comparison to chest CT referrals, the study authors found that neck CT requests had over a 3.7-fold higher likelihood of having sufficient quality but requests for head and abdominal CTs were 94 percent and 73 percent less likely, respectively, to have adequate information.
“Training on how to request meaningful radiology examinations after detailed clinical reasoning is warranted to improve radiology workflow for better medical practice,’ added Liu and colleagues.
(Editor’s note: For related content, see “Employing AI in Detecting Subdural Hematomas on Head CTs: An Interview with Jerely Heit, MD, PhD,” “FDA Issues Breakthrough Device Designation for AI-Powered Multi-Triage System for Computed Tomography” and “FDA Clears AI Software for Large Vessel Occlusion Detection on CT Angiography Scans.”)
Beyond the inherent limitations of a single-center retrospective study, the authors acknowledged that the CT requisition forms did not include all of the patient’s clinical information and conceded that only one radiologist evaluated the CT requisitions for the study. The researchers also noted a lack of assessment for variables, ranging from patient presentation severity to the experience of referring clinicians, that can affect the quality of CT referrals.
