title: CT in the Emergency Department: A Real-Time Study of Changes in Physician Decision Making.
abstract: OBJECTIVE
  To determine how physicians' diagnoses, diagnostic uncertainty, and management decisions are affected by the results of computed tomography (CT) in emergency department settings.
  
  
  METHODS
  This study was approved by the institutional review board and compliant with HIPAA. Data were collected between July 12, 2012, and January 13, 2014. The requirement to obtain patient consent was waived. In this prospective, four-center study, patients presenting to the emergency department who were referred for CT with abdominal pain, chest pain and/or dyspnea, or headache were identified. Physicians were surveyed before and after CT to determine the leading diagnosis, diagnostic confidence (on a scale of 0% to 100%), alternative "rule out" diagnosis, and management decisions. Primary measures were the proportion of patients for whom the leading diagnosis or admission decision changed and median changes in diagnostic confidence. Secondary measures addressed alternative diagnoses and return-to-care visits (eg, to emergency department) at 1-month follow-up. Regression analysis was used to identify associations between primary measures and site and participant characteristics.
  
  
  RESULTS
  Both surveys were completed for 1280 patients by 245 physicians. The leading diagnosis changed in 235 of 460 patients with abdominal pain (51%), 163 of 387 with chest pain and/or dyspnea (42%), and 103 of 433 with headache (24%). Pre-CT diagnostic confidence was inversely associated with the likelihood of a diagnostic change (P < .0001). Median changes in confidence were substantial (increases of 25%, 20%, and 13%, respectively, for patients with abdominal pain, chest pain and/or dyspnea, and headache; P < .0001); median post-CT confidence was high (95% for all three groups). CT helped confirm or exclude at least 95% of alternative diagnoses. Admission decisions changed in 116 of 457 patients with abdominal pain (25%), 72 of 387 with chest pain and/or dyspnea (19%), and 81 of 426 with headache (19%). During follow-up, 70 of 450 patients with abdominal pain (15%), 53 of 387 with chest pain and/or dyspnea (14%), and 49 of 433 with headache (11%) returned for the same indication. In general, changes in leading diagnosis, diagnostic confidence, and admission decisions were not well explained with site or participant characteristics.
  
  
  CONCLUSIONS
  Physicians' diagnoses and admission decisions changed frequently after CT, and diagnostic uncertainty was alleviated.
authors.affiliation: From the Department of Radiology (P.V.P., L.L.A., H.H.A., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Emergency Medicine (A.T.R., W.D.B.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Johns Hopkins University, Baltimore, Md (A.Z.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G., K.F.L.); Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); University of Massachusetts Medical School, Worcester, Mass (J.D.E.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (G.S.G.).
authors.forename: Pari V
authors.initials: PV
authors.lastname: Pandharipande
authors.affiliation: From the Department of Radiology (P.V.P., L.L.A., H.H.A., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Emergency Medicine (A.T.R., W.D.B.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Johns Hopkins University, Baltimore, Md (A.Z.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G., K.F.L.); Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); University of Massachusetts Medical School, Worcester, Mass (J.D.E.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (G.S.G.).
authors.forename: Andrew T
authors.initials: AT
authors.lastname: Reisner
authors.affiliation: From the Department of Radiology (P.V.P., L.L.A., H.H.A., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Emergency Medicine (A.T.R., W.D.B.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Johns Hopkins University, Baltimore, Md (A.Z.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G., K.F.L.); Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); University of Massachusetts Medical School, Worcester, Mass (J.D.E.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (G.S.G.).
authors.forename: William D
authors.initials: WD
authors.lastname: Binder
authors.affiliation: From the Department of Radiology (P.V.P., L.L.A., H.H.A., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Emergency Medicine (A.T.R., W.D.B.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Johns Hopkins University, Baltimore, Md (A.Z.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G., K.F.L.); Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); University of Massachusetts Medical School, Worcester, Mass (J.D.E.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (G.S.G.).
authors.forename: Atif
authors.initials: A
authors.lastname: Zaheer
authors.affiliation: From the Department of Radiology (P.V.P., L.L.A., H.H.A., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Emergency Medicine (A.T.R., W.D.B.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Johns Hopkins University, Baltimore, Md (A.Z.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G., K.F.L.); Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); University of Massachusetts Medical School, Worcester, Mass (J.D.E.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (G.S.G.).
authors.forename: Martin L
authors.initials: ML
authors.lastname: Gunn
authors.affiliation: From the Department of Radiology (P.V.P., L.L.A., H.H.A., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Emergency Medicine (A.T.R., W.D.B.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Johns Hopkins University, Baltimore, Md (A.Z.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G., K.F.L.); Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); University of Massachusetts Medical School, Worcester, Mass (J.D.E.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (G.S.G.).
authors.forename: Ken F
authors.initials: KF
authors.lastname: Linnau
authors.affiliation: From the Department of Radiology (P.V.P., L.L.A., H.H.A., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Emergency Medicine (A.T.R., W.D.B.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Johns Hopkins University, Baltimore, Md (A.Z.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G., K.F.L.); Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); University of Massachusetts Medical School, Worcester, Mass (J.D.E.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (G.S.G.).
authors.forename: Chad M
authors.initials: CM
authors.lastname: Miller
authors.affiliation: From the Department of Radiology (P.V.P., L.L.A., H.H.A., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Emergency Medicine (A.T.R., W.D.B.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Johns Hopkins University, Baltimore, Md (A.Z.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G., K.F.L.); Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); University of Massachusetts Medical School, Worcester, Mass (J.D.E.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (G.S.G.).
authors.forename: Laura L
authors.initials: LL
authors.lastname: Avery
authors.affiliation: From the Department of Radiology (P.V.P., L.L.A., H.H.A., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Emergency Medicine (A.T.R., W.D.B.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Johns Hopkins University, Baltimore, Md (A.Z.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G., K.F.L.); Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); University of Massachusetts Medical School, Worcester, Mass (J.D.E.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (G.S.G.).
authors.forename: Maurice S
authors.initials: MS
authors.lastname: Herring
authors.affiliation: From the Department of Radiology (P.V.P., L.L.A., H.H.A., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Emergency Medicine (A.T.R., W.D.B.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Johns Hopkins University, Baltimore, Md (A.Z.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G., K.F.L.); Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); University of Massachusetts Medical School, Worcester, Mass (J.D.E.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (G.S.G.).
authors.forename: Angela C
authors.initials: AC
authors.lastname: Tramontano
authors.affiliation: From the Department of Radiology (P.V.P., L.L.A., H.H.A., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Emergency Medicine (A.T.R., W.D.B.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Johns Hopkins University, Baltimore, Md (A.Z.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G., K.F.L.); Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); University of Massachusetts Medical School, Worcester, Mass (J.D.E.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (G.S.G.).
authors.forename: Emily C
authors.initials: EC
authors.lastname: Dowling
authors.affiliation: From the Department of Radiology (P.V.P., L.L.A., H.H.A., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Emergency Medicine (A.T.R., W.D.B.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Johns Hopkins University, Baltimore, Md (A.Z.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G., K.F.L.); Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); University of Massachusetts Medical School, Worcester, Mass (J.D.E.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (G.S.G.).
authors.forename: Hani H
authors.initials: HH
authors.lastname: Abujudeh
authors.affiliation: From the Department of Radiology (P.V.P., L.L.A., H.H.A., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Emergency Medicine (A.T.R., W.D.B.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Johns Hopkins University, Baltimore, Md (A.Z.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G., K.F.L.); Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); University of Massachusetts Medical School, Worcester, Mass (J.D.E.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (G.S.G.).
authors.forename: Jonathan D
authors.initials: JD
authors.lastname: Eisenberg
authors.affiliation: From the Department of Radiology (P.V.P., L.L.A., H.H.A., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Emergency Medicine (A.T.R., W.D.B.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Johns Hopkins University, Baltimore, Md (A.Z.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G., K.F.L.); Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); University of Massachusetts Medical School, Worcester, Mass (J.D.E.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (G.S.G.).
authors.forename: Elkan F
authors.initials: EF
authors.lastname: Halpern
authors.affiliation: From the Department of Radiology (P.V.P., L.L.A., H.H.A., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Emergency Medicine (A.T.R., W.D.B.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Johns Hopkins University, Baltimore, Md (A.Z.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G., K.F.L.); Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); University of Massachusetts Medical School, Worcester, Mass (J.D.E.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (G.S.G.).
authors.forename: Karen
authors.initials: K
authors.lastname: Donelan
authors.affiliation: From the Department of Radiology (P.V.P., L.L.A., H.H.A., E.F.H., G.S.G.), Institute for Technology Assessment (P.V.P., M.S.H., A.C.T., E.C.D., J.D.E., E.F.H., G.S.G.), Department of Emergency Medicine (A.T.R., W.D.B.), and Department of Medicine, Mongan Institute for Health Policy (K.D.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, Johns Hopkins University, Baltimore, Md (A.Z.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G., K.F.L.); Department of Radiology, Duke University Medical Center, Durham, NC (C.M.M.); University of Massachusetts Medical School, Worcester, Mass (J.D.E.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (G.S.G.).
authors.forename: G Scott
authors.initials: GS
authors.lastname: Gazelle
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003657:Decision Making; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011446:Prospective Studies; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*; D014481:United States