Achieving the Triple Aim Through Informed Consent for Computed Tomography

At the end of a particularly busy shift, you meet Mary, a 24 year-old female with no past medical history, who presents with six hours of crampy, intermittent, periumbilical abdominal pain but no associated fever, nausea, vomiting, diarrhea or anorexia. Her vital signs are normal and her abdominal and gynecological exams are notable only for mild, diffuse abdominal tenderness without rebound or guarding. Her lab results and urinalysis are unremarkable, and her pain improves somewhat with intravenous pain medications. You explain to the patient that you have a low suspicion for an intraabdominal emergency, but cannot be certain without a computed tomography (CT) scan. “I’ll do whatever you recommend,” she replies. The patient ultimately gets a CT, which is normal, and she is discharged 30 minutes later with a diagnosis of nonspecific abdominal pain. Emergency department (ED) clinicians see patients like Mary every daypatients for whom our experience and clinical suspicion of a truly emergent condition is low, albeit not negligible, and for whom there are no consensus, evidence-based guidelines or algorithms to guide the use of advanced imaging. The decision to image is, at times, dictated by systems-factors, such as difficulties arranging for adequate follow-up. Fear of litigation has been cited as a common driver of excessive diagnostic testing.1 Ultimately, diagnostic CT use in the ED is on a steep rise, which, combined with unchanging prevalence of disease, results in greater exposure to CT risks and costs with lower corresponding diagnostic yield.2-5 The risks (and costs) of CT are undeniably real and should not be ignored or minimized. Extrapolating from data from atomic bomb survivors, Smith-Bindman, Brenner and others have calculated the risks of cancer development associated with CT and estimated that up to 2% of all cancers in the US are attributable to CT scans.6,7 Beyond these theoretical extrapolations, Mathews and others demonstrated a doseresponse risk of cancer development associated with CT scans in a large cohort of patients in Australia.8 University of California, San Francisco, Department of Emergency Medicine, San Francisco, California