AIM: Do risk intolerance, malpractice fear drive head CT use?
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Conventional wisdom and prior findings hold that physician risk intolerance and malpractice fear fuel CT ordering; however, recent research disputes this assertion and suggests variations in head CT use in the emergency department (ED) do not correlate with these factors. The authors cautioned of caveats related to the findings, and emphasized that clinical decision support could improve quality, reduce inappropriate imaging and conserve healthcare resources, in an interview with Health Imaging and research letter published March 26 in Archives of Internal Medicine.

James E. Andruchow, MD, of the Center for Evidence-Based Imaging at Brigham and Women’s Hospital in Boston, and colleagues conducted a retrospective study of 7,905 patient encounters during the 2009 calendar year to examine predictors of head CT use in ED trauma patients.

“We hypothesized that variation exists in head CT use and is predicted by physician risk intolerance and malpractice fear,” wrote Andruchow and colleagues.

In an interview, Andruchow explained the rationale for the hypothesis. “Head CT can rule out potentially life-threatening diagnoses. Also, studies show physicians overestimate the likelihood of a finding on CT and the medicolegal risk of missing a critical finding on head CT.”  

However, the evidence did not support the researchers’ hypothesis.

The authors surveyed attending emergency physicians to quantify their risk tolerance and malpractice fear using the Risk Taking Scale, Stress from Uncertainty Scale and Malpractice Fear Scale, and also considered physician demographics.

The researchers found wide variation, from 7.2 percent to 41.7 percent of patient encounters, in head CT use. But their analysis showed physician demographic characteristics and risk taking, stress from uncertainty and malpractice fear were not predictive of CT use.  

Andruchow cautioned against reading too much into the results, explaining shared decision making at the level 1 academic trauma center may play an important, unexamined role in CT ordering patterns.

“We only measured risk intolerance of the single attending ED physicians,” he said. At Brigham, other stakeholders including residents, physician assistants and trauma and surgical teams are involved in the CT decision making process.

In contrast, ED physicians in community hospitals tend to play a much more individual and direct role in decision making. In those situations, the links between risk tolerance and fear of malpractice and head CT ordering may be more defined.

Next steps
Partners HealthCare is developing and implementing clinical decision support for head CT, basing the project on two well-validated rules for guiding head CT in trauma patients: the New Orleans Criteria and Canadian CT Head Rule.

One problem, said Andruchow, is that a lot of physicians in the U.S. are not familiar or comfortable with the rules.

Partners has successfully applied other decision support interventions. For example, decision support to guide CT angiography to rule out pulmonary embolism resulted in a 15 percent decrease in CT angiography in these cases.

The healthcare behemoth also developed a quality measure—appropriate head CT imaging for adults with mild traumatic brain injury—based on the American College of Emergency Physicians clinical policy, and is implementing clinical pathways across its hospitals to implement the quality measure, which also has been adopted by the National Quality Forum.

Andruchow and colleagues have developed physician education tools and flow sheets as well as research and data collection tools to measure baseline compliance and physician response.

He suggested institutional support for such pathways could reassure emergency physicians in community hospital settings. “With institutional buy-in, physicians can be more assured from a medicolegal and patient care standpoints that they are providing good care to their patients.”

The researcher concluded with a prediction: “Medicolegal risk and fear of malpractice contributes significantly to the use of healthcare resources in diagnostic imaging, admissions and consultations. This study addressed a complex decision-making environment. I think we would see stronger results [linking risk intolerance and malpractice fear with head CT use] in situations where there is a resident and single ED attending physician.” He also noted that in the future the Centers of Medicare & Medicaid Services may only reimburse for scans deemed appropriate, which may be an incentive to comply with decision tools sooner rather than later.