Patient preferences and acceptable risk for computed tomography in trauma
Introduction
The use of computed tomography (CT) in United States health care has increased significantly over the past few decades, from approximately 2 million scans performed in 1980 to 85.3 million in 2011 [1], [2], [3]. Similarly, emergency department (ED) advanced diagnostic imaging for injury (primarily CT) has increased from 6% of visits in 1998 to 15% in 2007, without corresponding increases in hospital admissions or diagnoses of life-threatening conditions [4]. This increased CT use exposes more patients to potentially harmful ionizing radiation, contributes to ED crowding, and generates annual radiographic charges approaching $100 billion [5].
Diagnostic medical imaging is a major source of non-natural radiation exposure, accounting for 15•20% of annual doses [6]. In the evaluation of patients with trauma, CT is the largest source of radiation [6]. When compared to plain chest radiographs, for example, CT scans involve as much as 119 times more radiation [1]. This ionizing radiation has been associated with an increased cancer risk in a linear, dose-dependent relationship [6], [7]. It is estimated that 1 in 270 women who undergo CT coronary angiography at age 40 will develop cancer as a direct result of the scan, and approximately 29,000 future cancers may be related to the CTs performed in the U.S. during 2007 alone [1], [7], [8]. Although public awareness of radiation risk is increasing, most patients still remain unaware of radiation exposure risk from CT [2], [9].
Respect for patient autonomy mandates providing informed consent for procedures that carry risk whenever possible. Yet, despite emerging knowledge about the potential cancer risks of CT, trauma imaging is typically obtained without informing patients of its risks or discussing their preferences. Patients may prefer to forego CT and accept a chance of missed injury in order to avoid the radiation exposure and costs of CT. Our objectives of this study were to determine (1) patient preferences for the discussion of risks and costs of CT during trauma evaluations in the ED, and (2) whether varying odds of detecting life-threatening injury (LTI) by CT changes these preferences. Knowledge of these patient preferences and risk tolerances may be useful to promote patient autonomy and shared decision making.
Section snippets
Study design, participants, and setting
We conducted this cross-sectional survey of ED patients who presented to four urban American College of Surgeons verified Level I trauma centres between July 2012 and April 2013. After providing a scripted consent that emphasised voluntary and anonymous participation, we surveyed a convenience sample of patients with the following exclusions: (1) receiving CT scan, (2) altered mental status, (3) intoxication, (4) critical illness, (5) incarceration, (6) psychiatric hold, and (7) inability to
Results
Of the 941 subjects enrolled, the mean age was 42 years and 50% were male. See Table 1 for complete subject characteristics.
Most subjects stated that they would prefer to discuss trauma CT radiation risks (73.5%, 95% CI [66.1, 80.8]) and costs (53.2%, 95% CI [46.1, 60.4]) with their physicians prior to receiving CT. As the hypothetical odds of LTI decreased, the desire for CT scan decreased accordingly: LTI 25% (desire 91.2%, 95% CI [89.4, 93.1]), LTI 10% (desire 79.3%, 95% CI [76.7, 81.9]),
Discussion
Similar to the recent work of Youssef et al., we found that nearly three quarters of non-critically ill patients want to discuss radiation risks before receiving CT (when possible) [17]. Considering that we asked these preference for discussion questions before presenting the statement about radiation risk, patients may already have been aware of some of these radiation concerns. Our study is novel in exploring variable acceptable risk thresholds and the effects of costs on preference for
Conclusions
Most non-critically injured ED patients prefer to discuss radiation risks and costs of CT prior to receiving imaging for trauma. As the odds of detecting LTI decrease, fewer patients prefer to have CT, and at an LTI threshold risk of <2%, approximately half of patients would prefer to forego imaging. Only one-third of patients desired CT imaging when out-of-pocket costs of $1000 were coupled with LTI risk <2%. Clarification of patient preferences may establish a new paradigm in advanced trauma
Author contributions
All authors contributed to the study design and implementation. All authors collected data, participated in ongoing site monitoring and provided supervision for the study. RMR, CLA, TH, and AR performed the data analysis. All authors contributed to interpretation of the analyses. RMR, TH and AR wrote the initial manuscript draft and all authors reviewed and contributed to its revision.
Conflict of interest statement
The authors have no conflicts of interest to declare regarding this research.
References (27)
- et al.
Incorporating patient preferences into practice guidelines: management of children with fever without source
Ann Emerg Med
(1994) - et al.
Admission decisions in emergency department chest pain patients at low risk for myocardial infarction: patient versus physician preferences
Ann Emerg Med
(1996) - et al.
Research electronic data capture (REDCap)- A metadata-driven methodology and workflow process for providing translational research informatics support
J Biomed Inf
(2009) - et al.
Emergency department patient knowledge, opinions and risk tolerance regarding computed tomography scan radiation
J Emerg Med
(2014) - et al.
Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study
Lancet
(2009) - et al.
Informed consent and parental choice of anesthesia and sedation for the repair of small lacerations in children
Am J Emerg Med
(1997) - et al.
Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer
Arch Intern Med
(2009) - et al.
Patient perceptions of computed tomographic imaging and their understanding of radiation risk and exposure
Ann Emerg Med
(2011) 2007 CT market summary report [International Marketing Ventures Web site]
(2008)- et al.
Use of advanced radiology during visits to US emergency departments for injury-related conditions, 1998•2007
JAMA
(2010)
The new era of medical imaging: progress and pitfalls
N Engl J Med
Radiation dose from initial trauma assessment and resuscitation: review of the literature
Can J Surg
Computed tomography•an increasing source of radiation exposure
N Engl J Med
Cited by (24)
An impact analysis of the NEXUS Chest CT clinical decision rule
2020, American Journal of Emergency MedicineCitation Excerpt :Additionally, when costs of CT are also considered, over half of them would choose to forego chest CT if they were found to be at low risk of missed injury scenarios. Although some clinicians may argue that there is no time to inform patients of the risks or costs of CT during trauma evaluation, we have demonstrated that informed consent is feasible in over two thirds of cases [23]. Ultimately, the NEXUS Chest CT Major CDR misses a very small number of CSIs, but costs much less and substantially decreases radiation exposure and cancer risk to patients.
Abandoning Further Study of the Application of Computed Tomography Decision Rules to Low-Risk Patients With Head Injury
2018, Annals of Emergency MedicineLow Yield of Paired Head and Cervical Spine Computed Tomography in Blunt Trauma Evaluation
2018, Journal of Emergency MedicineDevelopment of injury risk models to guide CT evaluation in the emergency department after motor vehicle collisions
2018, Traffic Injury PreventionSelective chest imaging for blunt trauma patients: The national emergency X-ray utilization studies (NEXUS-chest algorithm)
2017, American Journal of Emergency MedicineCitation Excerpt :Understanding that there is no “right” or “wrong” in this debate, we have presented summary algorithms that offer choices to suit the beliefs and preferences of individual practitioners and institutions. Furthermore, addressing this issue from the standpoint of patient-centered practice in one of our satellite studies, we demonstrated that patients wish to discuss risks and costs of CT and are willing to accept a small risk of missed injury in lower risk scenarios [33]. We present our summary algorithm for blunt trauma chest imaging in Fig. 1.
Prevalence of Chest Injury With the Presence of NEXUS Chest Criteria: Data to Inform Shared Decisionmaking About Imaging Use
2016, Annals of Emergency MedicineCitation Excerpt :However, these potential risks are either poorly quantified or completely unknown, limiting the extent to which outcome data can inform patient and physician shared decisionmaking about imaging. Physicians and patients need tools and data that provide accurate assessments of individual risks for significant clinical injury.7 The National Emergency X-Ray Utilization Study (NEXUS) chest decision instrument was derived and validated to decrease unnecessary thoracic imaging in patients with blunt trauma and has 99.7% sensitivity and 99.9% negative predictive value for excluding major thoracic injury observed on chest imaging.8