Trends in musculoskeletal imaging in trauma patients: how has our practice changed over time?

OBJECTIVES: The purpose of the study was to review diagnostic imaging in trauma patients. We hypothesized that diagnostic musculoskeletal imaging has increased over time, but at a lesser rate than radiography performed for other purposes. Two trauma centers were compared. DESIGN: Retrospective multicenter study. SETTING: Two level 1 trauma centers. PATIENTS/PARTICIPANTS: Five hundred patients per year from each trauma centers were reviewed for 2002, 2005, and 2008. MAIN OUTCOME MEASUREMENTS: Effective doses [millisieverts (mSv)] and total charges for radiography were calculated. RESULTS: Most imaging was performed within 24 hours of injury. In 2002, 15% of all radiographic studies were computed tomography (CT) scans compared with 33% in 2008 (P < 0.0001). Center 1 used more CT, and center 2 used more projection (plain) radiography. The percentage of musculoskeletal CTs increased from 26% in 2002 to 49% in 2008 (P < 0.0001), without change in patient acuity. The mean effective dose per patient was 17.3 mSv in 2002, 30.0 mSv in 2005, and 34.1 mSv in 2008 (P < 0.001). The percentage of total dose attributable to musculoskeletal studies increased from 25% in 2002, to 29% in 2005, and 31% in 2008 (P < 0.001). Mean total charges per patient were $4529 in 2002; $6922 in 2005; and $7750 in 2008 (P < 0.001), with higher 2008 mean charges at center 1 versus 2 ($8694 vs. $6806, P = 0.001), primarily because of more CT scans. CONCLUSIONS: The number of diagnostic imaging tests, radiation dose, and related charges in trauma patients increased over time at both trauma centers, with CT scans accounting for most of the radiation dose and costs. A shift toward more advanced imaging from conventional projection radiography was noted at both trauma centers. Effective dose per patient more than doubled over the course of study at center 1. By 2008, half of all radiographic studies were for musculoskeletal purposes. Previous studies have suggested an increased risk of cancer with exposures of 20-40 mSv, making the mean total radiation doses in excess of 30.0 mSv since 2005 of great concern. Variability in ordering patterns between the 2 centers with similar patient acuity suggests opportunity for discussion about indications for utilization, which could result in lower radiation doses and fewer expenses.

Radiation exposure has increased in trauma patients over time.

BACKGROUND: Computed tomography (CT) scans have become imaging modalities of choice in trauma centers. The purposes of this study were to evaluate the trend of radiation exposure in acute trauma patients. Our hypothesis was that radiation dosage and charges would increase over time without change in patient acuity or outcome. METHODS: Five hundred consecutive trauma patients were retrospectively reviewed for the years 2002, 2005, and 2008. Total number of CT scans, plain radiographs, and total radiation dosage (milliSieverts [mSV]) were determined. Charges were calculated. Injury severity scores and mortality were determined. RESULTS: The mean number of CT scans for category 1 patients in 2002, 2005, and 2008 was 1.5, 3.1, and 4.6, respectively (p = 0.01). This trend was similar in category 2 patients: 2.0, 3.5, 5.1, respectively (p < 0.01). Significant decreases in plain radiography were noted concurrently. This contributed to increased total radiation exposure to categories 1 and 2 patients over 2002, 2005, and 2008: 12.0 mSV, 23.6 mSV, and 33.6 mSV (p = 0.02); and 17.5 mSV, 24.1 mSV, and 37.5 mSV (p < 0.001), respectively. Charges for diagnostic imaging per patient also increased for categories 1 and 2 patients over 2002, 2005, and 2008: $2,933, $4,656, and $6,677; and $4,105, $5,344, and $7,365, respectively (all p < 0.01). Over the course of a year for 4,800 trauma patients treated at our hospital, this is expected to accrue additional charges of $13 million. CONCLUSION: The number of CT scans per trauma patient has more than doubled over 6 years, generating more radiation exposure and charges per patient, despite no change in mortality or injury severity. Judicious use of advanced imaging may control risks and costs without compromising care. LEVEL OF EVIDENCE: III, retrospective.