Mystery is Why, Not Who

Ordering of CT by Emergency Department Provider Type: Analysis of a Nationally Representative Sample

Objective Given the growing concern about CT overutilization, we provide a descriptive trend analysis of CT studies ordered in U.S. emergency departments by nonphysician health care providers and examine whether there is a significant difference in ordering patterns between nonphysicians and physicians.

Conclusion [N]onphysician health care providers are less likely to order CT compared with physicians. The types of ordering providers and their differing practices should become part of the discourse regarding appropriate CT utilization.

Mystery MD: Who is the gatekeeper of CT in the ED?

Nonphysicians increasingly turned to CT during the study period. In 2008, patient visits without a physician involved resulted in at least one CT exam 5.6 percent of the time. However, visits with a physician involved resulted in a CT exam 14.6 percent of the time. The researchers calculated that patients managed by nonphysicians had 0.38 times the odds of undergoing CT compared with those managed by physicians.

The findings suggest nonphysician providers are less likely to order a CT scan than physicians, but Lee and colleagues could not identify the reason. “It may be,” they wrote, “that nonphysician health care providers follow protocol-driven practices regarding CT ordering more strictly whereas physicians may be subjectively influenced by a strong concern for malpractice liability (given that ultimate legal responsibility for patient care belongs to supervising physicians.)”

Too obvious? Physicians and nonphysician providers in the ED see different patient populations based upon acuity. What studies are ordered is a function of how much time is spent in the triage process. Where an ED is front–loading the triage process, the goal is to drop the time patients spend in triage to both increase the triage throughput and drop the provider–to–patient time for patient satisfaction and hospital marketing purposes. Time is not sufficient to be precise, but it is sufficient to “shotgun” the studies to minimize the triage time, and also the downstream deposition time.

The mystery isn’t who does the ordering, but rather why the ordering is being done—is it always exclusively patient–centric?