title: Emergency department computed tomography utilization in the United States and Canada.
abstract: OBJECTIVE
  We compare secular trends in computed tomography (CT) utilization in emergency departments (EDs) in the United States and Ontario, Canada.
  
  
  METHODS
  Using a systematic survey in the US (The National Hospital Ambulatory Medical Care Survey) and administrative databases in Ontario, we performed a retrospective study of ED visits from 2003 to 2008. We calculated utilization overall, by visit characteristics, and for 5 clinical conditions in which CT is commonly indicated: abdominal pain, complex abdominal pain (abdominal pain, age ≥65 years, urgent to most urgent triage), admitted complex abdominal pain (abdominal pain, age ≥65 years, urgent to most urgent triage, and admitted to hospital), headache, and chest pain/shortness of breath. US data were weighted to produce national estimates.
  
  
  RESULTS
  On-site CT was available for 97% (95% confidence interval [CI] 95% to 99%) of visits in the United States compared with 80% (95% CI 80% to 80%) in Ontario. Visits were more frequently triaged as higher acuity in the United States than in Ontario, with 15.1% (95% CI 13.9% to 16.4%) of US visits categorized as most urgent versus 11.8% (95% CI 11.8% to 11.8%) in Ontario. The proportion of all ED visits in which CT was performed was 11.4% (95% CI 10.8% to 12.0%) in the United States versus 5.9% (95% CI 5.9% to 5.9%) in Ontario. The proportion for children was 4.7% (95% CI 4.3% to 5.1%) in the United States versus 1.4% (95% CI 1.4% to 1.4%) in Ontario. The rate of visits involving CT per year increased faster from 2003 to 2008 in the United States (odds ratio 2.00; 95% CI 1.81 to 2.21) than Ontario (odds ratio 1.69; 95% CI 1.68 to 1.70). Over time, all subgroups experienced increases in CT rate except Ontario children younger than 10 years, who experienced a significant decrease. United States-Ontario differences in CT proportions were significant among patients presenting with headache, abdominal pain, chest pain/shortness of breath, and complex abdominal pain. Proportions for visits involving admitted complex abdominal pain in the two jurisdictions were indistinguishable: 45.8% in the United States (95% CI 39.9% to 51.7%) versus 44.7% (95% CI 44.4% to 45.0%) in Ontario.
  
  
  CONCLUSIONS
  CT was more readily available in US EDs, and US clinicians used the technology more frequently than their colleagues in Ontario for nearly every category of patients, including children. CT utilization increased over time in both jurisdictions, but faster in the United States. Different demographic features between the two jurisdictions, including triage severity, frequency of hospitalization, and availability of CT scanners, likely account for at least some of the differences in CT utilization. Investigation of both clinical and nonclinical reasons for the differences in CT utilization between the United States and Canada would be a fruitful area for further research.
authors.affiliation: Department of Emergency Medicine, Los Angeles County and University of Southern California Medical Center, Los Angeles, CA. Electronic address: carlberdahl@gmail.com.
authors.forename: Carl T
authors.initials: CT
authors.lastname: Berdahl
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Department of Health Policy, Management and Evaluation, Toronto, ON, Canada.
authors.forename: Marian J
authors.initials: MJ
authors.lastname: Vermeulen
authors.affiliation: Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
authors.forename: David B
authors.initials: DB
authors.lastname: Larson
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Department of Health Policy, Management and Evaluation, Toronto, ON, Canada; Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Schull
mesh_terms: D015746:Abdominal Pain / Q000000981:diagnostic imaging*; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002170:Canada; D002648:Child; D002675:Child, Preschool; D004417:Dyspnea / Q000000981:diagnostic imaging*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006261:Headache / Q000000981:diagnostic imaging*; D019538:Health Care Surveys; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data* / Q000639:trends; D014481:United States; D055815:Young Adult