K. Habeeb1, T. R. Wojda1, A. Z. Hasani2, J. D. Nuschke2, Z. K. Zhang2, B. A. Hoey1, W. S. Hoff1, P. G. Thomas1, S. P. Stawicki1 1St. Luke’s University Health Network,Department Of Surgery,Bethlehem, PENNSYLVANIA, USA 2Temple University,St. Luke’s University Hospital Campus,Bethlehem, PA, USA
Introduction: Our group’s previous work suggested that greater "tonnage" of computed tomography (CT) for trauma may be associated with lower mortality. However, questions remain regarding the association between CT scan utilization and traumatologist level of experience. Based on empirical observations, we hypothesized that increasing provider experience may be associated with lower reliance on CT scanning, and that trauma fellows utilize CT imaging more than attendings.
Methods: Institutional registry consisting of 32,026 records (Jan 1998 – Dec 2015) at our Regional Level I Trauma Center was reviewed, excluding 4,346 patients who underwent emergency surgery or died before CT imaging was performed. The resulting sample was analyzed for: mortality, trauma provider level of training/experience, and CT scan “tonnage” per provider. We also collected demographic and injury information (gender, age, injury severity score [ISS], revised trauma score [RTS], mechanism). We then compared CT utilization and mortality between attendings and fellows during trauma resuscitation events (TRE). Data analyses were carried out using Chi-squared testing, Mann-Whitney U-testing or Analysis-of-Covariance (ANCOVA, correcting for injury mechanism and demographics), with statistical significance set at α=0.05.
Results: A total of 27,372 patient records were analyzed (60.3% male, median age 45 yrs, 95% blunt trauma, median ISS 5.00, median RTS 7.84, median hospitalization of 2 days). Seventy-nine ATLS-certified traumatologists (12 attendings, 67 fellows) were examined. Median mortality per traumatologist was 2.3%, with median number of 2.2 CT scans per TRE. There was no difference in average utilization of CT scans among attendings (2.1±0.1 per TRE) and fellows (2.2±0.1 per TRE). Patient mortality did not differ when the trauma team was led by an attending (3.7±0.2%) versus a fellow (3.3±0.4%). The number of CT’s per provider decreased with provider experience, with the median number of scans per TRE declining from 2.1 during the first decade of clinical experience to 1.9 during the subsequent decade in practice (p<0.05). The median number of CT scans for first year attendings (1.8 per TRE) was significantly lower than for first year fellows (2.2 per TRE, p<0.04). While the number of CTs per TRE increased to 2.3 among second year fellows (p<0.05), the same was not true for second year attendings.
Conclusion: We found important correlations between traumatologist level of experience and CT scan utilization. Despite lower utilization of CT scans among attendings, there was no associated mortality difference. Based on the overall number of CT scans performed during the entire study period, potential cost savings associated with fellows utilizing advanced imaging in-line with attending levels would amount to nearly $13 million, highlighting the need for clinical education in this important area.