Article, Emergency Medicine

US emergency department visits for adults with abdominal and pelvic pain (2007-13): Trends in demographics, resource utilization and medication usage

have long existed to extend our specialty services far from medical cen- ters, but the unprecedented growth of EDs is not occurring in the com- munities in most need [3]. They are built where residents have private insurance [4], far from public transportation, regardless of population density [5].

An “attractive” payer mix is profitable, especially under the old fee- for service model, but letting profit opportunity drive ED locations con- trary to patient needs opposes the ethos of our specialty and fails society in the long-term. Expansion into well-served markets increases health care utilization and costs [6] while we face cost-containment pressure. It does nothing to improve population health or access to care in urban and rural areas where hospitals are closing and need is greatest. The unregulated status that free-standing EDs enjoy where they are most numerous [7] is likely to change as insurers and legislators align payments with outcomes.

No doctor would triage patients by payment method and no doctor should work in a facility that has effectively done just that. If we no lon- ger serve all the critically sick and injured, then whom do we serve? Our specialty was founded to provide excellent care for the most challenging patients and this should be our guide to the future.

We should focus on improving Care coordination and addressing so- cial determinants of health. Any one of us could face uncoordinated doc- tors, transportation problems, strained caregivers, or addiction. Systems equipped to handle the most vulnerable patients will treat patients of any socioeconomic status well.

There is a role for Freestanding EDs for acute care access where hos- pitals can no longer operate. The certificate-of-need process, which re- quires community input and approval before a new center can open, is useful in assessing where those resources are needed.

At our origin we provided the care that was needed without regard for whether it was profitable. Our specialty has been wildly successful be- cause of it. Instead of turning away from our guiding principles, now more than ever, we must return to them. By providing excellent care to everyone who comes to our door, we will demonstrate our value to our policymakers, our colleagues, and most importantly, our patients.

Acknowledgment

The manuscript was copyedited by Linda J. Kesselring, MS, ELS, the technical editor/writer in the Department of Emergency Medicine at the University of Maryland School of Medicine.

Daniel B. Gingold, MD Robert M. Brown, MD*

Department of Emergency Medicine, University of Maryland School of

Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201,

United States

*Corresponding author.

E-mail address: [email protected] (R. M. Brown)

30 April 2017

https://doi.org/10.1016/j.ajem.2017.06.018

References

  1. Comstock N. Emergency medical treatment and Active Labor Act (EMTALA). January: Salem Press Encyclopedia; 2016.
  2. Sayah A, Lai-Becker M, Kingsley-Rocker L, Scott-Long T, O’Connor K, Lobon LF. Emer- gency department expansion versus patient flow improvement: impact on patient experience of care. J Emerg Med 2016;50:339-48.
  3. Schuur JD, Baker O, Freshman J, Wilson M, Cutler DM. Where do freestanding emer- gency departments choose to locate? A national inventory and geographic analysis in three states. Ann Emerg Med 2016 Jul 12 [Epub ahead of print].
  4. Simon EL, Griffin G, Orlik K, et al. Patient insurance profiles: a tertiary care compared to three freestanding emergency departments. J Emerg Med 2016;51(4):466-70.
  5. Carlson L, Baker O, Schuur J. 171 Emergency department proximity to public trans- portation: a comparison of freestanding and hospital emergency departments in three metropolitan areas. Ann Emerg Med 2016;68(4):S67.
  6. Simon EL, Griffin PL, Jouriles NJ. The impact of two freestanding emergency depart- ments on a tertiary care center. J Emerg Med 2012;43(6):1127-31.
  7. Gutierrez C, Lindor RA, Baker O, Cutler D, Schuur JD. State regulation of freestanding emergency departments varies widely, affecting location, growth, and services pro- vided. Health Aff (Millwood) 2016;35(10):1857-66.

    US emergency department visits for adults with abdominal and pelvic pain (2007-13):

    Trends in demographics, resource utilization and medication usage

    To the Editor:

    Abdominal pain is the most common complaint encountered in US emergency departments (EDs). In this study, we explored na- tional trends in recent years (2007-2013) in demographics, dispo- sition decisions, medication use, and CT scan utilization for adult ED patients with abdominal pain, using the National Hospital Am- bulatory Medical Care Survey (NHAMCS). NHAMCS is a yearly survey released by the Centers for Disease Control and Prevention (CDC) that can be used to make national estimates about U.S. ED visits. Changes in patient and hospital characteristics were investi- gated in NHAMCS using survey-weighted linear combinations of estimators. We also modeled the risk factors for two important public health issues surrounding abdominal pain: ED opioid anal- gesic use and CT scan utilization using a survey-weighted logistic regression.

    Overall, there were an estimated 18.7 million ED visits for abdom- inal pain in 2007 and 23.0 million in 2013 representing a 22.6% abso- lute increase over the 7-year interval, and a 7.7% relative increase compared to total ED visits. Over the study period, there were in- creases in the proportions of young patients, female patients, white patients, Medicaid patients, and patients who were ultimately discharged after ED care, specifically 5.3% more patients were discharged in 2013 as compared to 2007 (p b 0.05, Table 1).

    CT scans were used in 25.3% of all abdominal pain encounters in 2007, which peaked at 30.1% in 2010; subsequently, CT use trended downward to 28.6% in 2013. (Fig. 1) The leveling off of CT scans may reflect the success of campaigns that sought to raise awareness about radiation risks [1] or an increased cost-consciousness on be- half of doctors and patients [2]. Another possible explanation is that improvements in information technology have translated into fewer repeat CT scans. Patients were more likely to receive a CT scan if they were older, white, male gender, had private insurance, and reported severe pain. (Table 2) While the increase use in older adults may reflect an increased concern for ‘dangerous’ causes of ab- dominal pain and the decreased use in women may reflect concern about radiation in addition to the use of ultrasound for pelvic pathol- ogy, the decrease in non-white and Medicaid patients requires fur- ther investigation to explain.

    Medication use is extremely common in ED abdominal pain patients

    with N 85% of patients receiving medications in the ED. Over the study period, there was a 33.1% increase in the mean number of medications to 3.1 meds administered in the ED per patient per visit. Regarding opioid analgesics in particular, use increased from 35.2% to a peak of 39.4% in 2011 before falling to 34.4% in 2013: a 2.3% relative decrease over the 7 year period. Patients were more likely to receive opioids in the ED if they were white, younger than 65, had private insurance, or severe pain (N 8 on pain score). (Table 3) The leveling off of opioid use may also reflect increased public awareness of the adverse effects of opioid medications and abuse.

    Our study underscores the high resource intensity of caring for patients with abdominal pain in the ED. Of the approximately 20

    Correspondence / American Journal of Emergency Medicine 35 (2017) 19561983

    1967

    Table 1

    General trends.

    Characteristic

    2007

    95% CI

    2010

    95% CI

    2013

    95% CI

    Absolute change

    Relative change

    p-Value for trend

    Chi square

    Overall visits

    89,908,175

    (73,712,069-106,104,281)

    100,027,879

    (83,180,636-116,875,122)

    102,360,681

    (82,278,333-122,443,029)

    12,452,506

    13.9%

    Abdominal pain visits

    18,742,440

    (15,227,351-22,257,500)

    22,215,478

    (18,441,113-25,989,800)

    22,987,105

    (18,318,826-27,655,300)

    4,244,665

    22.6%

    Patient

    18-24

    24.5%

    (22.7-26.5)

    26.1%

    (24.3-27.9)

    27.2%

    (25.2-29.3)

    2.7%

    11.0%

    0.029

    0.544

    25-34

    23.4%

    (21.3-25.5)

    25.1%

    (23.4-26.9)

    25.3%

    (23.3-27.3)

    1.9%

    8.1%

    0.09

    35-44

    18.8%

    (17.0-20.7)

    21.9%

    (20.3-23.7)

    22.8%

    (20.9-24.8)

    4.0%

    21.3%

    0.004

    45-54

    18.7%

    (17.1-20.4)

    19.6%

    (18.3-21.0)

    18.8%

    (16.8-21.0)

    0.1%

    0.5%

    0.424

    55-64

    19.6%

    (17.8-21.6)

    20.4%

    (18.6-22.4)

    20.0%

    (17.8-22.3)

    0.4%

    2.0%

    0.863

    65 +

    19.7%

    (18.4-21.1)

    19.4%

    (18.2-20.7)

    20.6%

    (19.0-22.3)

    0.9%

    4.6%

    0.594

    Gender

    Male

    16.8%

    (15.8-17.8)

    17.5%

    (16.6-18.4)

    17.5%

    (16.5-18.4)

    0.7%

    4.2%

    0.111

    0.164

    Female

    24.0%

    (23.0-25.0)

    25.6%

    (24.5-26.8)

    26.1%

    (24.9-27.3)

    2.1%

    8.8%

    0.015

    Race

    White

    20.8%

    (19.8-21.7)

    22.1%

    (21.2-23.0)

    22.8%

    (21.8-24.0)

    2.0%

    9.6%

    0.002

    0.911

    Non-white

    21.1%

    (19.9-22.4)

    22.7%

    (21.6-23.8)

    21.3%

    (19.6-23.1)

    0.2%

    0.9%

    0.947

    Source of payment

    Private insurance

    22.5%

    (21.6-23.4)

    22.5%

    (21.4-23.7)

    23.3%

    (22.0-24.6)

    0.8%

    3.6%

    0.439

    0.023

    Medicaid

    21.6%

    (20.3-23.0)

    24.3%

    (22.8-25.8)

    24.7%

    (23.0-26.4)

    3.1%

    14.4%

    0.008

    Medicare

    19.6%

    (18.4-20.8)

    20.3%

    (18.9-21.7)

    21.2%

    (19.5-22.9)

    1.6%

    8.2%

    0.257

    Self-pay

    20.8%

    (19.1-22.5)

    21.7%

    (20.1-23.5)

    21.3%

    (19.4-23.3)

    0.5%

    2.4%

    0.154

    Previous care

    Seen within 72 h

    5.6%

    (4.7-6.6)

    5.4%

    (4.8-6.2)

    5.0%

    (4.0-6.3)

    -0.6%

    -10.7%

    0.958

    Disposition

    Discharged

    81.4%

    (79.3-83.3)

    81.3%

    (79.4-83.1)

    86.7%

    (84.4-88.7)

    5.3%

    6.5%

    0.001

    0.191

    Observation

    2.6%

    (1.9-3.6)

    2.7%

    (2.2-3.4)

    2.4%

    (1.5-3.8)

    -0.2%

    -7.7%

    0.826

    Admitted to floor

    17.3%

    (15.4-19.4)

    17.4%

    (15.6-19.3)

    12.0%

    (10.1-14.2)

    -5.3%

    -30.6%

    0.001

    Admitted to ICU

    Percent in severe pain (>= 8)

    1.3%

    (1.0-1.8)

    1.3%

    (1.0-1.7)

    1.3%

    (1.0-1.9)

    0.0%

    0.0%

    0.405

    34.7%

    (32.4-37.1)

    38.3%

    (36.2-40.4)

    34.9%

    (32.4-37.5)

    0.2%

    0.6%

    0.615

    Hospital

    Geographic region

    Northeast

    18.1%

    (16.5-19.9)

    20.0%

    (18.5-21.5)

    19.9%

    (17.5-22.6)

    1.8%

    9.9%

    0.246

    0.964

    Midwest

    20.7%

    (19.3-22.1)

    22.3%

    (20.6-23.9)

    23.1%

    (21.3-24.9)

    2.4%

    11.6%

    0.001

    South

    21.4%

    (20.4-22.4)

    22.5%

    (21.6-23.5)

    22.5%

    (21.2-23.9)

    1.1%

    5.1%

    0.266

    West

    22.5%

    (20.6-24.5)

    23.8%

    (22.4-25.4)

    23.4%

    (21.5-25.5)

    0.9%

    4.0%

    0.917

    Location

    Urban

    21.0%

    (20.2-21.8)

    22.7%

    (21.9-23.6)

    22.9%

    (21.9-23.8)

    1.9%

    9.0%

    0.001

    0.367

    Non-urban

    20.2%

    (18.3-22.3)

    19.8%

    (18.1-21.5)

    20.9%

    (18.6-23.3)

    0.7%

    3.5%

    0.32

    Type

    Non-profit

    20.9%

    (20.2-21.7)

    -20.9%

    -100.0%

    Government

    19.3%

    (17.2-21.6)

    -19.3%

    -100.0%

    For-profit

    21.8%

    (19.0-24.9)

    -21.8%

    -100.0%

    Teaching

    21.1%

    (19.5-22.7)

    23.8%

    (21.7-26.0)

    20.4%

    (17.3-23.8)

    -0.7%

    -3.3%

    0.879

    0.512

    Non-teaching

    20.8%

    (20.0-21.6)

    21.9%

    (21.1-22.7)

    22.7%

    (21.7-23.6)

    1.9%

    9.1%

    0.001

    Safety value

    b 50% poorly insured

    20.8%

    (20.0-21.6)

    22.3%

    (21.5-23.1)

    22.4%

    (21.4-23.3)

    1.6%

    7.7%

    0.002

    0.337

    >= 50% poorly insured

    22.4%

    (20.5-24.3)

    21.1%

    (18.1-24.3)

    23.9%

    (21.5-26.4)

    1.5%

    6.7%

    0.014

    Overall

    20.9%

    (20.1-21.6)

    22.2%

    (21.5-23.0)

    22.5%

    (21.6-23.4)

    1.6%

    7.7%

    0.006

    Fig. 1. CT scan utilization 2007-2017 95% CI.

    million ED visits each year, b 20% are admitted but over 50% receive diagnostic imaging. Approximately, 70% receive blood laboratory testing and 60% receive urine laboratory testing. The mean number of medications administered to each patient was N 3. Finally, the average length of stay is over 6 h for admitted patients and over 4 h for discharged patients.

    The observation that patient demographics and management has changed over this seven-year period raises the question of whether diagnoses also changed. In this study, traditional causes of emergency abdominal pain such as appendicitis, biliary disease,

    Table 2

    Predictors of CT use.

    abdominal hernia, Bowel obstruction, Peptic ulcer disease, pancre- atic disease and others remained stable. There was a decrease in Sexually transmitted diseases and noninfectious gastroenteritis. (Table 4.) Three diagnoses significantly increased over the study pe- riod: “other gastrointestinal disorders”, “nausea and vomiting,” and non-specific “abdominal pain” by 25.0%, 54.8% and 14.5%, respec- tively. (Table 4) All three are not truly diagnoses but non-specific categories that describe the symptomatology. This data suggests

    Table 3

    Predictors of opioid use.

    AOR of opioids 95% CI p-Value

    Age 18-24 *Ref

    AOR of CT

    95% CI

    p-Value

    25-34

    35-44

    1.38

    1.66

    (1.25-1.53)

    (1.48-1.86)

    0.001

    0.001

    Age

    18-24

    *Ref

    45-54

    1.45

    (1.30-1.62)

    0.001

    25-34

    1.36

    (1.20-1.55)

    0.001

    55-64

    1.19

    (1.04-1.37)

    0.012

    35-44

    1.67

    (1.46-1.92)

    0.001

    65 +

    0.6

    (0.51-0.71)

    0.001

    45-54

    2.09

    (1.82-2.40)

    0.001

    Race

    White

    1.55

    (1.40-1.71)

    0.001

    55-64

    2.2

    (1.91-2.54)

    0.001

    Non-white

    *Ref

    65 +

    2.19

    (1.89-2.55)

    0.001

    Sex

    Male

    *Ref

    Race

    White

    1.45

    (1.31-1.60)

    0.001

    Female

    1.04

    (0.96-1.13)

    0.335

    Non-white

    *Ref

    Payer

    Self-pay

    *Ref

    Sex

    Male

    *Ref

    Medicare

    0.95

    (0.84-1.07)

    0.394

    Female

    0.83

    (0.77-0.89)

    0.001

    Medicaid

    0.97

    (0.89-1.07)

    0.583

    Payer

    Self-pay

    *Ref

    Private

    1.12

    (1.03-1.22)

    0.007

    Medicare

    0.87

    (0.78-0.98)

    0.02

    Region

    Northeast

    *Ref

    Medicaid

    0.73

    (0.67-0.81)

    0.001

    Midwest

    1.47

    (1.22-1.77)

    0.001

    Private

    1.13

    (1.02-1.25)

    0.024

    South

    1.54

    (1.29-1.83)

    0.001

    Region

    Northeast

    *Ref

    West

    2.13

    (1.77-2.57)

    0.001

    Midwest

    0.89

    (0.78-1.00)

    0.056

    Teaching

    Non-teaching

    *Ref

    South

    0.84

    (0.74-0.95)

    0.004

    Teaching

    0.92

    (0.80-1.06)

    0.27

    West

    0.8

    (0.68-0.94)

    0.007

    MSA

    Rural

    *Ref

    Teaching

    Non-teaching

    *Ref

    Urban

    1.33

    (1.07-1.64)

    0.009

    Teaching

    0.82

    (0.72-0.94)

    0.005

    Imaging

    CT

    2.96

    (2.72-3.22)

    0.001

    MSA

    Rural

    *Ref

    Ultrasound

    1.57

    (1.38-1.77)

    0.001

    Urban

    1.53

    (1.31-1.79)

    0.001

    X-ray

    1.03

    (0.95-1.12)

    0.484

    Disposition

    Discharged

    *Ref

    Any procedure

    Yes

    1.98

    (1.79-2.18)

    0.001

    Observation

    1.14

    (0.93-1.39)

    0.196

    No

    *Ref

    Admitted

    1.56

    (1.41-1.73)

    0.001

    Disposition

    Discharged

    *Ref

    Admitted to ICU

    0.81

    (0.63-1.03)

    0.09

    Observation

    1.02

    (0.82-1.27)

    0.867

    Severe pain?

    Yes

    1.68

    (1.56-1.81)

    0.001

    Admitted

    1.27

    (1.14-1.42)

    0.001

    No

    *Ref

    Admitted to ICU

    0.58

    (0.45-0.73)

    0.001

    Any procedure

    Yes

    2.46

    (2.23-2.72)

    0.001

    Severe pain?

    Yes

    3.23

    (2.99-3.48)

    0.001

    No

    *Ref

    No

    *Ref

    *Ref = reference

    *Ref = reference.

    Correspondence / American Journal of Emergency Medicine 35 (2017) 19561983 1969

    Table 4

    Disease group.

    Group

    2007

    95% CI

    2010

    95% CI

    2013

    95% CI

    Absolute change

    Relative change

    p-Value for trend

    STDs

    4.1%

    (3.2-5.2)

    4.2%

    (3.5-5.0)

    1.7%

    (1.2-2.2)

    -2.4%

    -58.5%

    0.001

    Noninfectious gastroenteritis

    6.3%

    (5.2-7.6)

    2.5%

    (3.8-5.2)

    3.3%

    (2.7-4.2)

    -3.0%

    -47.6%

    0.001

    Other gastrointestinal disorders

    7.6%

    (6.8-8.6)

    7.8%

    (7.0-8.8)

    9.5%

    (8.3-10.9)

    1.9%

    25.0%

    0.001

    Nausea and vomiting

    8.4%

    (7.2-9.7)

    10.3%

    (9.2-11.5)

    13.0%

    (11.1-15.0)

    4.6%

    54.8%

    0.001

    Abdominal pain

    24.8%

    (23.3-26.5)

    27.4%

    (25.3-29.5)

    28.4%

    (26.0-30.9)

    3.6%

    14.5%

    0.001

    Other liver disease

    1.3%

    (0.9-1.8)

    1.2%

    (0.9-1.7)

    1.6%

    (1.2-2.3)

    0.3%

    23.1%

    0.101

    Appendicitis and related

    1.3%

    (0.9-1.9)

    0.9%

    (0.6-1.3)

    0.7%

    (0.4-1.1)

    -0.6%

    -46.2%

    0.144

    Abdominal hernia

    1.0%

    (0.7-1.3)

    1.5%

    (1.1-2.0)

    1.3%

    (0.9-1.9)

    0.3%

    30.0%

    0.177

    Esophageal disorders

    1.6%

    (1.2-2.1)

    1.2%

    (0.9-1.6)

    1.9%

    (1.4-2.6)

    0.3%

    18.8%

    0.319

    gastrointestinal hemorrhage

    2.4%

    (1.9-3.0)

    2.2%

    (1.8-2.7)

    2.1%

    (1.6-2.8)

    -0.3%

    -12.5%

    0.34

    Ovarian cyst

    1.8%

    (1.4-2.3)

    1.9%

    (1.5-2.4)

    2.0%

    (1.5-2.5)

    0.2%

    11.1%

    0.411

    Other disorders of kidney and ureter

    1.1%

    (0.8-1.5)

    0.6%

    (0.5-0.9)

    1.1%

    (0.7-1.7)

    0.0%

    0.0%

    0.477

    Diverticulitis

    1.6%

    (1.2-2.0)

    1.6%

    (1.2-2.0)

    1.8%

    (1.3-2.5)

    0.2%

    12.5%

    0.568

    Urinary tract infections

    11.6%

    (10.4-12.9)

    12.8%

    (11.7-14.1)

    11.5%

    (10.2-13.0)

    -0.1%

    -0.9%

    0.614

    Biliary tract disease

    2.4%

    (2.0-3.0)

    3.0%

    (2.5-3.5)

    2.6%

    (2.0-3.4)

    0.2%

    8.3%

    0.647

    Pancreatic diseases

    1.6%

    (1.2-2.1)

    1.8%

    (1.5-2.3)

    1.9%

    (1.4-2.6)

    0.3%

    18.8%

    0.662

    Calculus of urinary tract

    4.6%

    (3.9-5.3)

    3.5%

    (3.0-4.1)

    4.3%

    (3.6-5.2)

    -0.3%

    -6.5%

    0.807

    Other disorders of stomach and duodenum

    1.9%

    (1.4-2.6)

    2.1%

    (1.6-2.7)

    2.2%

    (1.5-3.3)

    0.3%

    15.8%

    0.819

    Gastritis and duodenitis

    2.7%

    (2.1-3.5)

    2.7%

    (2.2-3.2)

    2.6%

    (2.0-3.2)

    -0.1%

    -3.7%

    0.914

    intestinal obstruction

    1.4%

    (1.1-1.9)

    1.2%

    (0.9-1.6)

    1.5%

    (1.0-2.1)

    0.1%

    7.1%

    0.967

    Diseases of the urinary tract

    1.3%

    (0.9-1.7)

    1.4%

    (1.1-1.8)

    1.5%

    (1.1-2.1)

    0.2%

    15.4%

    0.996

    that despite the high intensity of diagnostic testing, physicians often still lack the ability to tell patients what is causing their symptomatology.

    In conclusion, we found there as increase in both absolute num- bers and overall percentage of patients presenting to EDs for abdom- inal pain. Younger patients, female patients, white patients, and patients who are ultimately discharged are increasingly being seen in EDs for abdominal pain. CT utilization and opioid analgesic use appear to have leveled off and declined slightly which may reflect successful public health campaigns to reduce the use of these resources in the ED.

    Prior presentations

    None.

    Funding sources/disclosures

    N/A/none.

    ACM – reports no conflicts of interest JPM – reports no conflicts of interest LMR – reports no conflicts of interest PMM – reports no conflicts of interest MMA – reports no conflicts of interest

    Peter Mullins, MD, MBA, MSCE Center for Healthcare Innovation and Policy Research, The George Washington University School of Medicine and Health Sciences,

    Washington, DC, United States

    Maryann Mazer-Amirshahi, PharmD, MD, MPH Department of Emergency Medicine, MedStar Washington Hospital Center and the Georgetown University School of Medicine, Washington, DC,

    United States

    8 May 2017

    https://doi.org/10.1016/j.ajem.2017.06.019

    References

    Green SM. When do clinical decision rules improve patient care? Ann Emerg Med 2013;62:132-5.

  8. Brenner DJ, Hall EJ. Computed tomography-an increasing source of radiation expo- sure. N Engl J Med 2007;357:2277-84.

    patient preference to participate in shared decision making for performing a CT scan in the emergency department

    Acknowledgments

    None.

    Andrew C. Meltzer, MD, MS* Lorna M. Richards, MA

    To the Editor:

    Computerized tomography imaging is widely used in US emergency departments (ED) and represents a major source of carcino- genic radiation [1]. There is evidence that patients desire to be made aware of potential risks associated with radiation exposure [2]. Shared Decision Making (SDM) is a principle of the doctor-patient relationship

    Department of Emergency Medicine, George Washington University,

    Washington, DC, United States

    *Corresponding author at: George Washington University, Department of Emergency Medicine, 2120 L Street NW, Suite 450, Washington, DC

    20027, United States.

    E-mail address: [email protected] (A. C. Maeltzer).

    Jesse M. Pines, MD, MBA, MSCE Departments of Emergency Medicine and Health Policy & Management, The George Washington University, Washington, DC, United States

    that involves sharing of information and the agreement about which therapeutic option to implement. SDM has been used successfully in clin- ical decisions such as hospital admissions for chest pain and surgery for appendicitis [3,4]. It is currently unknown if shared decision making is beneficial in the decision to order a CT scan in the ED. As part of a pilot study with the eventual goal of creating a decision aid to facilitate shared decision making about CT scans, our objective was to assess the desire of ED patients to participate in the decision process regarding CT scan use. Our secondary objective was to describe differences in patients who want to participate versus those who do not want to participate.

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