A Systematic Review of the Determinants of Overuse of Radiologic Services in the Emergency Department

Introduction. Overuse of radiologic services, where imaging tests are provided under circumstances where the propensity for harm exceeds the propensity for benefit, comprises a risk to patient safety and a burden on health... [ view full abstract ]

Introduction. Overuse of radiologic services, where imaging tests are provided under circumstances where the propensity for harm exceeds the propensity for benefit, comprises a risk to patient safety and a burden on health systems. However, the patient, physician, and systemic level determinants that drive these unnecessary scans are poorly defined. We aimed to identify determinants of overused imaging in the Emergency Department (ED).

Methods. Paired reviewers systematically searched for relevant published literature in PubMed and Embase from January 1996 to October 2016. One reviewer extracted key data and a second verified the accuracy. The determinants of overuse were qualitatively synthesized.  

Results. Twenty-one articles were included. Fifteen evaluated use of computerized tomography (CT) scans in patents presenting to a regional ED who were transferred to a level 1 trauma center. Nine described reasons for duplicate scanning; incomplete transfer of images with the patient and poor image quality were most frequently reported. Factors significantly associated with unnecessary pre-transfer scanning or repeated scanning after transfer, in multiple studies, included older patient age, higher injury severity score and greater distance between hospitals. The included studies mostly had moderate risks of bias, with poor reporting of participant characteristics and little attention to confounding.

Conclusions. This is a heterogeneous body of literature and the quality of the studies is sub-optimal. Older patient age and greater injury severity were the most consistently cited significant determinants of imaging overuse in the ED.  Duplicate scanning in transferred trauma patients was the most frequently described type of overuse in this population of patients. Technological failures in the transfer of data should be remediable, which would reduce overuse of duplicate scanning in this setting.