The Joint Commission Journal on Quality and Patient Safety November 2012 Volume 38 Number 11 483 Edward R. Melnick, MD; Christopher M. Szlezak, MD; Suzanne K. Bentley, MD; James D. Dziura, PhD; Simon Kotlyar, MD, MSc; Lori A. Post, PhD T he United States and its health care system are in a finan- cial crisis. According to a recent report by the Institute of Medicine, up to $750 billion of health care spending per year yields no patient benefits. 1 Overuse, “the provision of med- ical services with no benefit or for which harms outweigh bene- fits,” 2(p.171) accounts for a large part of this waste. Although computed tomography (CT) has greatly improved diagnostic ability, it exposes patients to ionizing radiation and subsequently a risk of cancer. 3 The use of CT is growing at an alarming rate, with nearly 70 million scans performed annually in the United States. 4–8 Although the use of CT scans for injury- related emergency department (ED) visits has tripled in 10 years, there has been no increase in the diagnosis of life-threatening conditions or admission rates. 9 More than 1.3 million patients are treated and released from EDs annually for mild traumatic brain injury (MTBI) in the United States. 10 Minor head injury is defined as blunt trauma to the head and a history of loss of con- sciousness, amnesia, or disorientation and a Glasgow Coma Scale (GCS) score of 13–15. 11 Most minor head injuries are mild, but in a small proportion of patients clinical deterioration occurs. 12 In patients with clinically important brain injury, CT imaging yields a quick and accurate diagnosis such that neurosurgical in- tervention can potentially prevent deleterious outcomes from in- tracranial hematoma. 11 Overuse of CT adds to health care costs and can subject pa- tients to unnecessary cancer risk. 3,6 The radiation dose of a rou- tine head CT is approximately 2 millisieverts. 6 The risk of cancer associated with this ionizing radiation dose is age and gender specific, with a rough order of magnitude of one radiation-in- duced cancer per 10,000 CTs performed in adult patients. 6 Cur- rent practice does not mandate that the provider and patient discuss the risks associated with CT scans. 13 To prevent overuse of CT and to differentiate MTBI from clin- ically important brain injury, multiple evidence-based guidelines exist to direct appropriate use of CT—four high-quality guide- lines that are frequently used in practice include the Canadian Overuse CT Overuse for Mild Traumatic Brain Injury Article-at-a-Glance Background: Multiple, validated, evidence-based guide- lines exist to inform the appropriate use of computed to- mography (CT) to differentiate mild traumatic brain injury (MTBI) from clinically important brain injury and to pre- vent the overuse of CT. Yet, CT use is growing rapidly, potentially exposing patients to unnecessary ionizing radia- tion risk and costs. A study was conducted to quantify the overuse of CT in MTBI on the basis of current guideline recommendations. Methods: A retrospective analysis of secondary data from a prospective observational study was undertaken at an urban, Level I emergency department (ED) with more than 90,000 visits per year. For adult patients with minor head injury receiving CT imaging at the discretion of the treating physician, the proportion of cases meeting criteria for CT on the basis of the Canadian CT Head Rule (CCHR), American College of Emergency Physicians (ACEP) Clini- cal Policy, New Orleans Criteria (NOC), and National In- stitute for Health and Clinical Excellence (NICE) guidelines was reported. Results: All 346 patients enrolled in the original study were included in the analysis. The proportion of cases meeting criteria for CT for each of the guidelines was: CCHR 64.7% (95% confidence interval [CI], 0.60–0.70), ACEP 74.3% (95% CI, 0.70–0.79), NICE 86.7% (95% CI, 0.83–0.90), and NOC 90.5% (95% CI, 0.87–0.94). The odds ratio of the guidelines for predicting positive head CT findings were also reported. Discussion: Some 10%–35% of CTs obtained in the ED for MTBI were not recommended according to the guidelines. Successful implementation of existing guidelines could de- crease CT use in MTBI by up to 35%, leading to a significant reduction in radiation-induced cancers and health care costs. Copyright 2012 © The Joint Commission