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Group 6Comparative Effectiveness Research: Alternatives to Traditional CT Use
Research questions: Overall considerations in comparative effectiveness of CT use
Can (and how can) decision support improve the comparative effectiveness of imaging
approaches in the ED?
What is the long-term benefit/harm of incidental findings on CT and how does that
impact the comparative effectiveness of imaging approaches?
What is the incremental impact on comparative effectiveness of various imaging
approaches (standard CT, reduced dose CT, point-of-care or radiology ultrasound, no
imaging) for incidental findings in abdominal imaging?
When can dual energy CT be used to improve the comparative effectiveness of imaging
in the ED population?
What is the actual harm of radiation from CT and how does that impact the
comparative effectiveness of CT use?
How can we improve the speed/ accessibility of MRI to improve comparative
effectiveness of imaging?
Does reduced dose CT provide a benefit or harm compared to regular CT in terms of
incidental findings identified?
Which uses of standard CT in the ED are most amenable to comparative effectiveness
research (in terms of overall utilization, harms of radiation, practice variation)?
How do we best quantify the diagnostic benefit of CT (and other imaging approaches)
in terms of information gained for estimating comparative effectiveness (can we
standardize "bits of information gained")?
How do we change the culture of imaging to implement the most comparatively
effective approaches?
What is the most effective imaging approach for facilities with limited or unavailable
MRI (when MRI may be the most effective approach)?
Can (and how can) improved technical support (such as an on site physicist, improved
education, etc.) impact the adoption of comparatively more effective approaches?
Would understanding the cumulative radiation doses that a patient has received
previously help improve comparative effectiveness of CT use?
Research questions: Comparative effectiveness of CT in trauma
In which blunt trauma patients is it beneficial to obtain whole body CT imaging as
compared to selective use of CT?
In pediatric patients with minor head injury and/or headache, is rapid MRI brain as
effective a diagnostic approach to standard, non-contrast CT?
What is the optimal use of CT in pediatric blunt abdominal or chest trauma (compared
to history and physical, radiography, ultrasound, MRI)?
When should CT (vs. MRI or plain radiography) be used in suspected cervical spine
injury?
How does pan scan impact: operative intervention, mortality, incidental findings, ED
length of stay, resource utilization and availability, radiation exposure, etc.?
What is the optimal use of CT chest in blunt chest trauma in conjunction with clinical
signs, symptoms, radiography, and ultrasound?
Could reduced dose or dual energy CT be as effective an approach in trauma imaging as
standard CT?
What is the optimal use of abdominal CT in blunt abdominal trauma based on clinical
signs and symptoms, radiography, and ultrasound?
What is the comparative effectiveness of clinical assessment, radiography/ CT/ MRI for
suspected traumatic thoracic and/or lumbar spine injury?
What is the optimal approach to the diagnosis of suspected pediatric cervical spine
injury?
When should MRI, scintigraphy, or follow-up radiography be used instead of CT when
there is a suspicion for traumatic musculoskeletal injury with equivocal radiography
(e.g. spine, hip, tibial plateau, scaphoid, foot)?
Are there biomarkers that are as effective as CT in the evaluation of traumatic brain
injury?
Research Questions: Atraumatic Headache
In pediatric patients with minor head injury and/or headache, is rapid MRI brain as
effective a diagnostic approach as standard, non-contrast CT?
What is the optimal diagnostic imaging strategy in patients with clinical concern for
stroke presenting within the window for thrombolytic therapy?
What is the optimal diagnostic imaging strategy in patients with clinical concern for
atraumatic subarachnoid hemorrhage?
What is the optimal diagnostic imaging strategy in patients with clinical concern for
transient ischemic attack with resolution of symptoms?
What is the optimal diagnostic imaging strategy in patients with clinical concern for
central vertigo or suspected posterior circulation ischemia?
Does rapid MRI or reduced-dose CT provide a comparatively more effective approach
than standard CT in the evaluation of ventriculoperitoneal shunt malfunction?
In what situations is imaging comparatively more effective than symptom control in
patients with headache, absent neurologic symptoms, and concern for intracranial
mass?
Research questions: Comparative effectiveness of CT in non-traumatic chest pain and/
or dyspnea:
Would age- or situation-specific D-dimer cutoffs (i.e. in pregnancy) help optimize
appropriate CT imaging in suspected pulmonary embolism?
For patients with negative or inconclusive chest radiography performed for pneumonia,
does a regular or reduced dose CT of the thorax improve patient-centered outcomes to
identify occult pneumonia?
In patients with clinical concern for ACS what is the comparative effectiveness of coronary
CT in relation to: serial troponin, provocative testing, and/or cardiac catheterization?
Is there a benefit to using dual energy CT in suspected pulmonary embolism/ aortic
dissection/ acute coronary syndrome?
Could the use of D-dimer and/or bedside ultrasound help improve the comparative
effectiveness of CT angiography for suspected thoracic aortic dissection?
Research questions: Comparative effectiveness of CT in non-traumatic abdominal and
flank pain:
In suspected appendicitis what is the comparative effectiveness of different diagnostic
approaches compared to standard CT in different populations (i.e. by age and sex)? I.e.
how do history, physical, laboratory, point-of-care ultrasound, radiology ultrasound,
focused and/or reduced dose CT or MRI as a first approach compare?
What is the optimal diagnostic approach to suspected pediatric appendicitis with nondiagnostic ultrasound?
In suspected kidney stone, what is the optimal diagnostic imaging strategy using clinical
prediction rules, point-of-care or radiology ultrasound, and reduced dose CT compared
to standard, non-contrast CT?
How does reduced dose CT affect diagnostic accuracy for common abdominal
conditions (i.e. appendicitis, bowel obstruction, diverticulitis) in various patient
populations (i.e. by age, sex, and size) and how does this affect the comparative
effectiveness of diagnostic approaches?
In patients with suspected bowel obstruction what is the best imaging approach? Is
there a role for radiography and/or ultrasound? What is the optimal use of contrast?
How does ultrasound first performed by emergency providers compared to standard
CT with respect to accuracy, length of stay and cost for renal, pelvic, cardiac and biliary
indications?
What is the optimal diagnostic imaging strategy for premenopausal women with
undifferentiated, acute lower abdominal/pelvic pain that may be due to
gastroenterological or gynecological pathology?
Can dual energy CT be as effective an approach to acute, atraumatic abdominal pain as
standard CT?