ED labels 84% of its abdominal ultrasound exams as inappropriate, causing downstream problems

Abdominal pain is among the reasons patients visit the emergency department, with CT and ultrasound both serving as front-line tests to assess such complaints. New data suggests, however, that many of these exams are ordered inappropriately, leading to negative downstream consequences.

That’s what researchers discovered after analyzing more than 250 exams completed at a non-trauma tertiary care hospital over a three-month span. Based on the American College of Radiology appropriateness criteria, 36% of CT scans were inappropriately ordered along with 84% of ultrasound exams.

Guideline-discordant US images also caused providers to utilize an additional imaging modality in 20% of cases, causing longer ED stays, extra tests, and added costs, the authors wrote Sunday in Current Problems in Diagnostic Radiology.

The reasons for these high numbers are multifaceted, but malpractice fears and concerns over missing a low-probability diagnosis likely top the list, Martina Zaguini Francisco, MD, with the Federal University of Health Sciences of Porto Alegre in Brazil, and colleagues explained.

The team also pointed to educational gaps as a sizable problem.

“Although there is wide and ready dissemination of ACR tools, the lack of awareness of existing guidelines remains a major problem,” Zaguini et al. wrote. “This results not only in imaging overuse but also in wrong modalities being requested, leading to additional imaging orders during the same visit.”

More than 85% of emergency physicians admit to ordering too many tests, the researchers explained. And exams may be considered inappropriate for many reasons, including choosing the wrong modality, opting for one test over a more appropriate first-line exam, or if a test doesn’t change therapeutic management.

With this in mind, Zaguini et al. retrospectively reviewed 135 CT and 143 US exams ordered for abdominal complaints in the ED between January and March 2019.

They found that appropriately ordered exams were “significantly” more likely to yield findings compatible with clinicians’ initial diagnosis.

“This highlights the high impact that correct exam selection has on finding confirmative or actionable results on imaging,” the authors wrote.

Based on ACR Appropriateness Criteria, inappropriate CT scans were most often ordered for biliary disease, pancreatitis, renal failure, and uncomplicated pyelonephritis.

For ultrasound, meanwhile, discordant exams were typically requested for acute abdominal pain, uncomplicated pyelonephritis, diverticulitis, and appendicitis.

The study was limited by its single-center design and may not be generalizable to other organizations, the authors noted.