Computed Tomography Imaging in the Management of Headache in the Emergency Department: Cost Efficacy and Policy Implications

Purpose: To evaluate the economic impact and diagnostic utility of computed tomography (CT) in the management of emergency department (ED) patients presenting with headache and nonfocal physical examinations. Methods and Materials: Computerized medical records from 2 major community hospitals were retrospectively reviewed of patients presenting with headache over a 2.5-year period (2003-2006). A model was developed to assess test outcomes, CT result costs, and average institutional costs of the ED visit. The binomial probabilistic distribution of expected maximum cases was also calculated. Results: Of the 5510 patient records queried, 882 (16%) met the above criteria. Two hundred eighty-one patients demonstrated positive CT findings (31.8%), but only 9 (1.02 %) demonstrated clinically significant results (requiring a change in management). Most positive studies were incidental, including old infarcts, chronic ischemic changes, encephalomalacia, and sinusitis. The average cost of the head CT exam and ED visit was $764 (2006 dollars). This was approximately 3 times the cost of a routine outpatient visit (plus CT) for headache ($253). The incremental cost per clinically significant case detected in the ED was $50078. The calculated expected maximum number of clinically significant positive cases was almost 50% lower than what was actually detected. Conclusion: Our results indicate that emergent CT imaging of nonfocal headache yields a low percentage of positive clinically significant results, and has limited cost efficacy. Since the use of CT for imaging patients with headache in the ED is widespread, the economic implications are considerable. Health policy reforms are indicated to better direct utilization in these patients.