Is CTA overused in the emergency department?

CT angiography (CTA) may be overused in the emergency department and have low clinical value, according to research published March 21 in Internal and Emergency Medicine.

A team led by Marc Succi, MD, from Massachusetts General Hospital found that CTA use for patients with headache or dizziness has increased over a five-year period in the emergency department at a large medical center. At the same time, the rate of positive findings on these exams has decreased, indicating that CTA use has low value in many patients.

“Prudent imaging use is essential for cost reduction and efficient patient triage,” the Succi team wrote.

CTA detects damaged blood vessels in the brain, which leads to quick treatment for conditions such as brain injuries, aneurysm, or stroke. However, its use is not clinically appropriate for many cases where the primary symptom is headache or dizziness, according to the American College of Radiology (ACR).

Succi and colleagues studied trends in head and neck CTA ordering, focusing on whether a correlation exists between imaging use and rates of positive exams. They included retrospective data from a level 1 trauma center that evaluates about 110,000 emergency department patients each year.

The team reported that CTA rates for headache and dizziness increased from 7.89% of emergency visits in 2017 to 13.24% in 2021. This equates to a 67.4% increase over the study period. Also, a patient with headache and/or dizziness was 15% more likely on average to have a CTA in 2021 versus 2017.

The researchers also studied whether this reported increase was influenced by greater severity in emergency patients by evaluating the rate of positive findings on CTA exams. They found that the rate of positive findings dropped by 38% over the study period.

And while the total number of CTA exams increased from 422 in 2017 to 662 in 2021, the number of patients with an abnormality detected dropped slightly from 71 to 69. Finally, the team reported that patients with private insurance were more likely to have a CTA exam, while the likelihood of a CTA was less for Black patients compared with their white counterparts.

The study authors suggested that based on their findings, hospitals should proactively work toward appropriate imaging for these patients and reduce low-value imaging.

"This study sheds light on increasing utilization of head and neck CTAs for certain patients in the emergency department and raises signifcant concerns for potential overuse of advanced neuroimaging modalities in the emergency department," they wrote.

The authors also called for future research to study the underlying reasons for increasing neuroimaging utilization rates as well as the effectiveness of protocols currently governing head and neck CTA ordering for headaches and dizziness in emergency settings.    

The study can be found in its entirety here.

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