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Use interventions, curb unnecessary imaging
Study: Patients don't understand benefits, risks
While experts might differ regarding the extent of risk posed by radiation exposure from computed tomography (CT) scans and other imaging procedures, there is broad consensus that this risk should be minimized, especially in young patients. However, it's clear that curtailing the unnecessary use of imaging is particularly challenging in EDs where the need for a quick diagnosis often will overshadow such concerns and where there is generally much less time to delve into a patient's imaging history. Provider-focused interventions, including education as well as safety precautions, are important in curbing unnecessary radiation exposure, but there is new evidence that patient-focused education can make a difference as well.
"We don't always know what patients have had done before they come to us. We are often limited to our own medical records," explains Brigitte Baumann, MD, MSCE, head, division of clinical research, emergency medicine, Cooper University Hospital, Camden, NJ. "If a patient has been to another hospital [previously], they may not be forthcoming or may not be aware of what was done because they don't remember or realize what type of issue they had."
In such cases, it is difficult to guide patients appropriately regarding future imaging studies, allows Baumann, but that's just problem number one, she emphasizes. The other problem is that many patients just aren't satisfied with their ED evaluation unless an imaging study is completed. "This touches on how confident patients are in their medical evaluation. Sometimes if you have a patient who is very demanding or feels they need imaging done, [physicians] can feel pushed to do that type of study more," she says.
After observing this type of patient behavior firsthand and hearing of instances when patients were receiving multiple scans within a short time, Baumann decided to look into the issue. He conducted a cross-sectional study of 1,168 patients who came into the ED complaining of abdominal pain. Using a 100-point scale, patients were asked to indicate what their confidence was in a medical evaluation with and without ancillary testing. The results were fairly clear. The median confidence level for evaluations without testing was 20, but that number jumped to 90 when laboratory testing and CT were included in the evaluation.1
However, Baumann also determined that patients have a poor understanding of the radiation exposure associated with CT, with more than 70% of the study participants underestimating the radiation dose of CT when compared with chest radiography. Also, study results show that many of the participants had a poor understanding of their imaging history. Out of the 365 patients who reported that they had never undergone a CT, researchers found that 39% of this group had a CT documented in the hospital's electronic medical record (EMR).
Explain risks, benefits to patients
Baumann's findings suggest that patient-focused initiatives could play a strong role in improving safety and minimizing the use of unnecessary imaging in the ED setting. She points out that in many cases, a brief conversation with the patient about the benefits and risks of a CT scan is enough for the patient to back off demands for imaging when a more conservative approach is available.
Baumann recalls a recent case where this type of intervention worked well. "I had a patient who came in who had a history of kidney stones. She was upset and clearly in pain. She was probably having another stone crisis, but her pain had only been there for six to eight hours," explains Baumann. "She was very adamant about having a CT scan. She wanted to know what was going on."
However, the patient informed Baumann that she had undergone about six scans in the previous three years, so Baumann explained the risks posed by radiation exposure from repeated scans and proposed an alternative treatment plan.
"After our conversation, she was amenable to watching and waiting, and giving it a little bit of time," Baumann says. "We sent her home with some pain medication and also some other medication that would help to flush out the stone ... because many patients do end up passing stones on their own."
Get patients to track imaging history
Northwest Community Hospital in Arlington Heights, IL, plans to take the concept of patient education one step further by creating a "radiology passport," a card that patients can carry with them that details their imaging history as well as how much radiation exposure is attributed to each study, explains Allan Malmed, MD, the vice chairman of radiology at Northwest.
However the hospital has taken several other steps to minimize radiation exposure from the use of CT. For example, whenever a study is ordered, the technologists are trained to check to see whether the patient already has undergone the same study. If the study already has been conducted, the technologists relay this information to the ordering physician, says Malmed.
The hospital also has set all of its CT scanners to use 60% of the radiation level recommended by the American College of Radiology. Malmed explains that the image quality is good enough to provide physicians with the information they need while delivering added safety for patients. In addition, Malmed is adamant about using shields to cover eyes, breasts, and other body parts so that they are not exposed unnecessarily to radiation, and he has trained staff to narrow the focus of the CT scan so that the scan includes only the area that the physician needs. "Most of these steps are invisible to the patient, but the right things to do for safety," he says.
Malmed acknowledges that it took time to get staff on board with all of these steps. It helps to have a physician champion, a technologist champion, and administrative support, he says. Furthermore, he recommends regular audits to make sure the staff is consistently adhering to the practices.
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Time to raise awareness on pediatric imaging?
Children are considered at higher risk from radiation exposure associated with imaging procedures such as CT scans, but they nonetheless frequently undergo such procedures, according to a new study published in the Archives of Pediatrics and Adolescent Medicine.1
The retrospective study identified 355,088 children under age 18 in five regions to track how frequently imaging procedures were used over three years. Researchers found that more than 436,711 procedures were performed on 150,930 of the children, all of whom received at least one procedure. One-fourth of this group received two or more imaging procedures, and 16% underwent three or more procedures.
The most common procedure performed in the study group was chest radiography, although 8% of the children received a CT scan during the study period, and 3.5% received more than one CT scan. Routine x-rays use much lower doses of radiation than CT, so the use of CT in children is of particular concern, noted the authors. Based on the study data, the researchers reported that the average child in the study would be expected to receive seven procedures using radiation by age 18.
The findings suggest more awareness about the frequent use of these tests may be needed, says, the lead author of the study, Adam Dorfman, MD, clinical assistant professor of pediatrics and communicable diseases and clinical assistant professor of radiology at the University of Michigan Medical School in Ann Arbor. He further pointed out that while imaging tests are a critical component of good medical care, the high number of tests raises questions about whether providers are being judicious in their use of the technology.