Understanding Overuse of Computed Tomography for Minor XXXX in the Emergency Department: A Triangulated Qualitative Study.

@entity1 @entity341 @entity542 @entity148
BACKGROUND: Overuse of computed tomography (CT) for minor @entity542 continues despite developed and rigorously validated clinical decision rules like the Canadian CT Head Rule (CCHR). Adherence to this sensitive and specific rule could decrease the number of CT scans performed in minor @entity542 by 35%. But in practice, the CCHR has failed to reduce testing, despite its accurate performance. OBJECTIVES: The objective was to identify nonclinical, @entity1 factors that promote or inhibit the appropriate use of CT in @entity1 presenting to the @entity341 ( @entity341 ) with minor @entity542 . METHODS: This was a qualitative study in three phases, each with interview guides developed by a multidisciplinary team. Subjects were recruited from @entity1 treated and released with minor @entity542 and providers in an urban academic @entity341 and a satellite community @entity341 . Focus groups of @entity1 (four groups, 22 subjects total) and providers (three groups, 22 subjects total) were conducted until thematic saturation was reached. The findings from the focus groups were triangulated with a cognitive task analysis, including direct observation in the @entity341 (>150  hours), and individual semistructured interviews using the critical decision method with four senior physician subject matter experts. These experts are recognized by their peers for their skill in safely minimizing testing while maintaining @entity1 safety and engagement. Focus groups and interviews were audio recorded and notes were taken by two independent note takers. Notes were entered into ATLAS.ti and analyzed using the constant comparative method of grounded theory, an iterative coding process to determine themes. Data were double-coded and examined for discrepancies to establish consensus. RESULTS: Five core domains emerged from the analysis: establishing trust, @entity148 ( @entity1 and provider), constraints related to @entity341 practice, the influence of others, and @entity1 expectations. Key themes within these domains included @entity1 engagement, provider confidence and experience, ability to identify and manage @entity1 @entity148 , time constraints, concussion knowledge gap, influence of health care providers, and @entity1 expectations to get a CT. CONCLUSIONS: Despite high-quality evidence informing use of CT in minor @entity542 , multiple factors influence the decision to obtain CT in practice. Identifying and disseminating approaches and designing systems that help clinicians establish trust and manage uncertainty within the @entity341 context could optimize CT use in minor @entity542 .
