Thurs., 10/13/11 Polytrauma, Paper #26, 2:51 pm OTA-2011
Trends in Musculoskeletal Imaging for Trauma Patients: How Has our Practice Changed Over Time?
Frank A. Forde, BS1; Kasra Ahmadinia, MD1; Charles Ekstein, BS2;
Paul Tornetta, III, MD2; Heather A. Vallier, MD1;
1MetroHealth Medical Center, Cleveland, Ohio, USA;
2Boston University Medical Center, Boston, Massachusetts, USA
Purpose: Utilization of advanced diagnostic imaging has escalated over time. Emergent CT scans account for much of the increased usage in trauma patients. Previous work showed substantial increases in usage of CT scans within the 24 hours of admission in trauma patients over time, with no change in patient acuity. The purpose of the study was to review the experience of 2 major Level 1 trauma centers and determine the amount of musculoskeletal imaging versus other studies throughout the hospital course. We hypothesized that the frequency of musculoskeletal imaging has increased over time, but at a lesser rate than other radiography. With enhanced understanding of the indications and ordering patterns for various tests, there may be opportunities for more judicious utilization.
Methods: 300 consecutive trauma patients per year from 2 urban Level 1 trauma centers were retrospectively reviewed for 2002, 2005, and 2008. Radiographic tests included plain radiographs (XR), CT scans, and MRI. Tests were characterized as to body location, day of hospitalization, department of the ordering physician, and radiation dosages (mSv). Total charges for radiography were calculated, including professional and technical charges, standardized to 2008 charges for Center 1. Length of stay and ISS were determined for each patient.
Results: The majority of diagnostic imaging was done within 24 hours of injury: 76% in 2002, 70% in 2005, and 69% in 2008; thus, the majority of radiation was also received in the first 24 hours. The mean number of all studies per patient (XR + CT + MRI) performed at Center 1 was 9.6, 10.3, 13.0 in 2002, 2005, and 2008, respectively, during the entire hospital course. The mean number of studies per patient at Center 2 was 18.3, 21.9, and 19.3 in 2002, 2005, and 2008. Usage of CT scans was higher in Center 1 at all time points, while usage of plain XR was higher in Center 2, resulting in a larger number of total studies in Center 2. Center 2 had a trend toward more usage of musculoskeletal CT scans on subsequent days of hospitalization, but the percentage of studies that were musculoskeletal was stable at both centers at 25% over the period of study. In 2002, 20% of all radiographic studies were CT scans, while in 2008, 35% were CT scans (P <0.0001), the majority of which were not musculoskeletal. During this time no change in patient acuity as measured by ISS or length of stay was seen. CT scans accounted for the majority of all radiation in trauma patients. Significant increases in radiation were seen over time at both centers, with mean radiation per patient of 16.6 mSv in 2002, 28.5 mSv in 2005, and 37.4 mSv in 2008 (P <0.0001). The percentage of total radiation attributable to musculoskeletal studies increased from 25% in 2002, to 29% in 2005, and 31% in 2008 (P <0.001). Mean total charges per patient for radiographic tests significantly increased between 2002 and 2008: $4,345 in 2002, $5,539 in 2005, and $8,222 in 2008 (P <0.001).
Conclusion: The number of diagnostic imaging tests, radiation, and charges in trauma patients increased over time at both trauma centers, with CT scans the majority of the radiation and costs. Most of the imaging was completed within 24 hours. Radiation per patient more than doubled over the course of study. Approximately 25% of radiographic tests were for musculoskeletal purposes, and the increasing usage of musculoskeletal CT scans resulted in a significantly larger percent of radiation attributable to these tests over time. Previous studies have suggested an increased risk of cancer with exposures of 20 to 40 mSv, making the mean total radiation dosages of 28.5 mSv in 2005 and 37.4 mSv in 2008 of great concern. Variability in ordering patterns between the 2 centers with similar patient acuity and length of stay suggests opportunity for discussion about indications for utilization, which could result in lower radiation and expenses.
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• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.