CT improves primary care docs’ diagnoses, decisions and confidence

Primary care providers (PCPs) tend to change their leading diagnoses and have more confidence in their subsequent care decisions after receiving results from CT exams, according to a prospective, multicenter study running in the August edition of Radiology.

Pari Pandharipande, MD, MPH, of Harvard Medical School and colleagues concluded so after reviewing surveys completed by 91 PCPs treating 373 patients.

Focusing on treatment for three conditions common to the primary-care setting—abdominal pain, hematuria and weight loss—the researchers surveyed PCPs before and after they ordered CTs on an outpatient basis.

The participants recorded their leading diagnosis, confidence in that diagnosis (confidence range, 0 percent to 100 percent), a rule-out diagnosis and a management plan if CT were not available.

The before-and-after responses showed that providers changed their diagnoses in 57 percent of the weight-loss cases (27 of 47 cases), 53 percent of the abdominal pain cases (131 of 246) and 49 percent of the hematuria cases (36 of 73).

Moreover, the PCPs changed their care-management decisions at the rate of 54 percent for weight-loss patients, 35 percent for abdominal-pain patients and 27 percent for hematuria patients.

The most common adjustment to care management involved continued PCP management versus referral to a specialist or transfer to an emergency department.

In patients with abdominal pain, changes from specialist referral before CT to continued PCP management after CT were more frequent than the other way around (46 percent [40 of 87] versus 20 percent [28 of 140).

As for diagnostic confidence levels, the PCPs recorded substantial and significant increases after CT for all three conditions—a lift of 20 percent or very close to it—and median post-CT diagnostic confidence levels were uniformly high (90 percent, 88 percent and 80 percent).

In their discussion, the authors note that many CT scans and their radiation doses could be safely avoided if point-of-care methods were available to reliably identify patients in whom CT is unlikely to affect decision-making to the benefit of the patient.

Clinical decision support tools “may bring us closer to this goal in the future,” they add, urging further research to establish the tools’ capability in this regard.

“More broadly, our results suggest that, at present, PCP referral practices for CT in the everyday scenarios addressed are likely to substantially affect clinical decision-making,” they conclude, “and underscore the importance of additional research to support careful granular approaches to safely reduce CT use in primary care settings.”