Overnight subspecialty coverage pushes CT use higher in community EDs

Overnight imaging subspecialty coverage—as opposed to a more traditional model of on-call preliminary interpretations by a resident—resulted in an increase in CT utilization in community emergency departments (EDs), according to a study published in the September issue of the American Journal of Roentgenology.

Utilization in academic center EDs that instituted overnight subspecialty coverage did not rise significantly, however, and despite the increase at the community centers, CT utilization in community EDs remained below the level seen in the academic core, according to Mitchell Tublin, MD, of the University of Pittsburgh School of Medicine, and colleagues.

“Models of academic radiology coverage of emergency on-call cross-sectional studies have evolved over the past five years,” they wrote. “Preliminary interpretations of increasingly complex imaging studies by trainees—with final reviews by attending radiologists during daytime hours—are often no longer considered acceptable despite the rarity of significant discordances.”

To examine the effect of overnight subspecialty coverage on overall CT utilization, Tublin and colleagues examined CT volume at the University of Pittsburgh Medical Center, which instituted overnight neuroradiology and abdominal imaging attending coverage in 2008. The authors tracked total CT volume, ED visits and CT intensity (CT volume/ED visits) in both academic and community hospitals for the 12 months before and after implementing overnight coverage.

Although initially concerned that the new model would increase CT utilization throughout the medical center, this was not the case in academic EDs, reported Tublin et al. CT volume in these department increased 8 percent, but this was commensurate with an increase in overall ED visits.

The community centers, on the other hand, saw increases in CT volume of 9 percent, while overall ED visits decreased 3 percent during the study period. “It may be that community emergency department physicians more aggressively used subspecialty CT interpretations to mirror the use in academic sites and to help guide care in settings in which access to in-house clinical consultants may have been limited,” wrote the authors.

Academic ED CT intensity remained constant at 0.57, and community ED CT intensity increased from 0.40 to 0.45, a 12.5 percent jump.

Tublin and colleagues also noted that the length of stay within EDs at both the academic and community centers decreased over the study period, but because of parallel initiatives, these decreases could not be attributed to the addition of subspecialty coverage. The new model appears not to have hindered department workflow, however.

The authors said their coverage model is unique and other providers could learn from their experiences. Future studies will need to be conducted to determine the model’s effect on imaging appropriateness and its clinical impact.