Computed Tomographic Angiography and Yield for Gastrointestinal Bleeding in the Emergency Department
Siona Prasad1,2, C Michael Hood1,2,3, Cameron Young1,2
1Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Mass General Brigham, Boston, Massachusetts.
Insights
Computed tomographic angiography (CTA) use for gastrointestinal bleeding (GIB) in the emergency department (ED) significantly increased from 2017 to 2023. However, the diagnostic yield of CTA for detecting active bleeding declined substantially during this period.
Area of Science:
- Radiology
- Gastroenterology
- Emergency Medicine
Background:
- Advanced imaging, such as computed tomographic angiography (CTA), is increasingly utilized in emergency departments (EDs).
- While CTA is recommended for diagnosing acute gastrointestinal bleeding (GIB), its escalating use may not proportionally enhance the detection of active bleeding.
- Overutilization of imaging contributes to increased healthcare costs, reduced ED efficiency, and patient crowding.
Purpose of the Study:
- To analyze trends in CTA utilization for suspected GIB within the ED setting.
- To evaluate changes in the diagnostic yield of CTA for GIB over time.
Main Methods:
- A retrospective cohort study was conducted at an urban academic medical center from January 2017 to December 2023.
- The study included adult patients undergoing abdominal and pelvic CTA for suspected GIB in the ED.
- Primary outcomes included the annual volume and proportion of GIB-related CTAs among all ED CT scans, and the secondary outcome was the test-positive proportion (diagnostic yield).
Main Results:
- The number of GIB-related CTAs rose from 0.09% in 2017 to 0.65% in 2023.
- The diagnostic yield (test-positive proportion) decreased from 20.0% in 2017 to 6.3% in 2023.
- Multivariable analysis indicated that increased age was associated with higher odds of a positive CTA, while more recent calendar year and active cancer were associated with lower odds.
Conclusions:
- CTA utilization for suspected GIB in the ED has markedly increased, while its effectiveness in detecting active bleeding has diminished.
- This trend necessitates a careful balance between the diagnostic benefits of CTA and its associated costs, radiation exposure, and operational impact.
- Evidence-based ordering guidelines and clinical decision support tools are crucial for optimizing CTA use in the ED evaluation of GIB.
Importance:
Overuse of advanced imaging in the emergency department (ED) contributes to higher costs, reduced efficiency, and crowding. Computed tomographic angiography (CTA) is a recommended first-line diagnostic for acute gastrointestinal bleeding (GIB), yet its increasing use may not always improve detection of active bleeding.
Objective:
To evaluate recent trends in CTA use for suspected GIB in the ED and assess changes in diagnostic yield.
Design, Setting, And Participants:
This retrospective cohort study included all adult patients who underwent CTA of the abdomen and pelvis for suspected GIB at a 1011-bed urban academic medical center between January 2017 and December 2023.
Exposure:
Suspected GIB prompting a CTA order in the ED.
Main Outcomes And Measures:
The primary outcome was the annual number and proportion of GIB-related CTAs among all ED computed tomography (CT) examinations. The secondary outcome was the test-positive proportion (diagnostic yield), defined as the percentage of CTAs showing active bleeding or evidence of hemorrhage. All CTAs were interpreted by board-certified emergency radiologists and reviewed by a fellowship-trained emergency radiologist.
Results:
Among 954 ED patients (mean [SD] age, 66.7 [6.3] years; 427 female [44.8%]), the number of GIB-related CTA examinations increased from 30 of 32 197 ED CT examinations (0.09%) in 2017 to 288 of 44 423 (0.65%) in 2023. Over the same period, the test-positive proportion declined from 6 of 30 (20.0%) in 2017 to 18 of 288 (6.3%) in 2023. Multivariable analysis showed that more recent calendar year was associated with lower odds of a test-positive examination (OR, 0.84; 95% CI, 0.73-0.96; P = .01), older age with higher odds (OR, 1.02; 95% CI, 1.00-1.04; P = .02), and active cancer with lower odds (OR, 0.35; 95% CI, 0.12-1.00; P = .05).
Conclusions And Relevance:
CTA use increased substantially over 7 years while diagnostic yield declined. This trend highlights the need to balance the diagnostic benefit of CTA with interpretation time, radiation exposure, and operational strain. These findings support a need for evidence-based ordering criteria and decision-support tools to help guide CTA use in the ED evaluation of gastrointestinal bleeding.
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