Postgraduate Medicine
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Predictors of Excessive CT Scan Use in a Surgical Cohort of Patients With Crohn's Disease Whitney Young MD, Neil Hyman MD & Turner Osier MD To cite this article: Whitney Young MD, Neil Hyman MD & Turner Osier MD (2013) Predictors of Excessive CT Scan Use in a Surgical Cohort of Patients With Crohn's Disease, Postgraduate Medicine, 125:6, 94-99 To link to this article: http://dx.doi.org/10.3810/pgm.2013.11.2716
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C L I N I C A L F E AT U R E S
Predictors of Excessive CT Scan Use in a Surgical Cohort of Patients With Crohn’s Disease
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DOI: 10.3810/pgm.2013.11.2716
Whitney Young, MD 1 Neil Hyman, MD 1 Turner Osler, MD 1 Department of Surgery, University of Vermont College of Medicine, Burlington, VT 1
Abstract
Background: Patients with Crohn’s disease typically undergo computed tomography (CT) scans periodically over the course of their chronic disorder, requiring only modest doses of ionizing radiation. However, previous studies have suggested there is a subgroup of patients with Crohn’s disease who undergo frequent CT scans with an associated increase in health care expenditures and possible overexposure to radiation, potentially placing such patients at increased risk for cancer. The aim of our study was to characterize and define this potentially vulnerable cohort using a relatively homogeneous surgical population. Methods: Consecutive patients who underwent ileocolic resection for Crohn’s disease from January 2000 to September 2010 at an academic medical center were identified from a prospectively maintained database. Only patient CT scans remote from surgery or hospitalization were considered in the analysis. The number of outpatient CT scans, physician visits, and coexisting psychiatric and functional diagnoses were recorded from retrospective chart review. Patients who were considered high CT scan utilizers were compared with patients who were low utilizers. Results: Sixty-three patients underwent 126 CT scans during the study period, however, 4 of the patients accounted for 52 (41%) of the studies. Compared with the overall study population, the subset of 4 patients (high utilizers) had a median of 66 clinic visits (P , 0.001) and 40 emergency department visits (P , 0.001). All 4 patients were on chronic narcotic medication, and only 1 did not have a concomitant functional disorder. Missed appointments and the absence of prescribed antidepressants were common among patients with high CT use. Conclusions: Although use of CT appears moderate in surgical patients with Crohn’s disease overall, there is a subset of patients with chronic pain and psychiatric diagnoses, who frequently miss appointments, and account for a markedly disproportionate number of scans performed. Interestingly, use of antidepressants in patients with Crohn’s disease was strongly associated with fewer scans, suggesting an opportunity for therapeutic intervention. Keywords: computed tomography scan; Crohn’s disease; surgery; radiation
Introduction
Correspondence: Neil Hyman, MD, Department of Surgery, University of Vermont College of Medicine, Fletcher 465, Burlington, VT 05401. Tel: 802-847-2194 Fax: 802-846-5579 E-mail: [email protected]
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Patients with Crohn’s disease frequently require radiologic imaging studies to evaluate abdominal symptomatology, often incurring considerable resource costs, while being exposed to significant ionizing radiation.1–3 As Crohn’s disease is a chronic and relapsing condition that often affects young people,4 the cumulative effects may be substantial over the course of a lifetime. Exposure to high levels of ionizing radiation exposure is linked to an increased risk for developing malignancy.5,6 The use of computed tomography (CT) imaging has substantially increased in recent years,7,8 therefore, justifiable concern has been expressed about the risk of radiation-induced carcinoma in patients with Crohn’s disease.
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Predictors of Excessive CT Use in Surgical Patients With Crohn’s Disease
Previous studies have shown that a subset of patients with Crohn’s disease are exposed to considerably higher doses of radiation owing to the frequency of radiologic evaluations.9,10 It has been our experience that these are usually patients whose abdominal symptoms cannot be readily ascribed to disease-related activity, but they still undergo repetitive imaging studies that rarely demonstrate new findings or change patient management regimens. Patients with Crohn’s disease usually have a relationship with their primary care provider, a gastroenterologist, surgeon, and potentially, a host of emergency department (ED) physicians, so there are many opportunities for redundant care. It seems evident that new or different strategies are required to improve the effectiveness of care and outcomes in this high-use cohort. The aim of our study was to characterize the subgroup of patients with Crohn’s disease who undergo frequent CT scans in the hope that recognition of these patients might lead to more fruitful approaches to disease management, or, at least prevent excessive use of CT scans in this subpopulation. On the basis of clinical observation, we hypothesized that of those patients with Crohn’s disease, patients who were frequent CT scan users would also be characterized by markedly greater overall resource utilization, including more ED visits, more cancelled or no-show appointments, and have increased functional and psychiatric diagnoses.
Methods
All Vermont residents aged .18 years, undergoing elective ileocolic resection for histopathologically proven Crohn’s disease at Fletcher Allen Health Care, the teaching hospital of the University of Vermont College of Medicine (Burlington, VT), between January 2000 and September 2010, were identified from a prospectively maintained surgical complication database. A cohort of patients with terminal ileal disease alone or in combination with right colon involvement was chosen to enhance homogeneity and assure that the diagnosis of Crohn’s disease was based on tissue diagnosis. Patients who lived out of state, were institutionalized, cognitively impaired, or aged , 18 years were excluded because they did not necessarily have routine follow-up care for disease management at our institution. Fletcher Allen Healthcare is a tertiary care referral center serving Vermont and upstate New York. Approximately 40% of patients who undergo surgery for Crohn’s disease at our institution are New York State residents who are typically cared for by primary care physicians and gastroenterologists back home. Demographic data collected included patient age, sex, ethnicity, town or city of residence in Vermont, and the
duration of diagnosis of Crohn’s disease before surgery. The number of visits to the gastroenterology outpatient clinic, surgery outpatient clinic, and the ED for Crohn’s disease-related symptoms and management was recorded. The frequency of cancelled and no-show appointments was collected based on the electronic appointment scheduling system records. The number of other diagnostic studies, such as colonoscopies and small bowel series for the study duration were determined by review of patient radiologic and endoscopy folders. The outpatient clinic records and problem lists were evaluated for chronic use of narcotics, specific non-narcotic pain medications (such as amitriptyline, pregabalin, and gabapentin), and treatment with antidepressants (defined as $ 6 months of continuous use). Psychiatric diagnoses, including major depression, schizophrenia, personality disorder, or somatoform disorder were recorded. In addition, concomitant diagnoses of chronic pain syndrome(s) and functional disorders were assessed from the medical record; these included chronic pelvic pain, neck pain, back pain, jaw pain, headaches, or fibromyalgia. The CT scans were classified as either in-patient or outpatient based on the patient status at the time of the imaging and hospital admission dates as documented in the electronic or paper medical records. Patients with Crohn’s disease who were not admitted to the hospital after CT scans were performed were considered to have had outpatient studies. To avoid the confounding contribution of medical and surgical complications to the analysis, in-patient CT scans and those performed within 30 days of surgery were excluded. The goal was to exclude all scans performed to assess, track, or manage postoperative complications so that only CT scans performed to e valuate symptoms remote from surgery would be included. Similarly, we excluded all other in-patient CT scans because they were usually obtained to exclude a disease-specific complication before a change in medical management during symptomatic exacerbation requiring hospital admission (eg, to rule out an abscess before initiating treatment with steroids or a biologic). For the purpose of comparative analysis, 2 groups were defined: patients with $ 8 outpatient CT scans during the 10-year study period were considered frequent CT scan utilizers and were compared with patients who were low CT scan utilizers, having undergone , 8 scans. Several patient characteristics were compared between the 2 groups; because these characteristics were skewed in their distributions, the Mann–Whitney–Wilcoxon test was used throughout. Our study was approved by the Institutional Review Board of the University of Vermont College of Medicine.
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Young et al
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Results
Table 2. Characteristics of High CT Scan Utilizers (N = 4)
Sixty-three patients satisfied inclusion criteria for the study. Median patient age was 49 years (range, 24–81 years), and 40 patients were women (63.4%). The length of follow-up ranged from 2 to 11 years (mean, 6.2 years). All patients carried the diagnosis of Crohn’s disease for $ 1 year before surgery and had histopathologic confirmation of the diagnosis based on review of the surgical specimen. Twenty-four patients (38%) had a concomitant diagnosis of a chronic pain syndrome; 21 patients (33%) were on chronic narcotics; 10 patients (15.8%) took non-narcotic pain medication, such as gabapentin, on a chronic basis; and 15 patients (23.8%) regularly used antidepressants. Twenty five patients (39.5%) had a psychiatric diagnosis, usually depression, and 18 patients (28.5%) had $ 1 functional diagnosis. The number of patient arrived and missed physician visits and common diagnostic assessments are listed in Table 1. Although the number of evaluations and physician visits for most patients is generally modest, there is a remarkable range in our total study patient population. For example, the median number of surgery clinic visits during 10 years was 4, but the range was 0 to 60. Similarly, for gastrointestinal (GI) clinic visits, the median was 11, with a range from 0 to 100. The number of CT scans per patient ranged from 0 to 18. The high CT scan utilizers (n = 4) included 2 men and 2 women patients. The 4 patients had 8, 10, 16, and 18 CT scans, respectively, during the study period. Forty of 52 CT scans (77%) in this patient group were obtained in the ED. All 4 patients had a diagnosis of chronic pain syndrome, all were taking narcotics chronically, 3 had a history of depression, and 3 had $ 1 functional disorders. Two patients were taking antidepressants. One of these patients had 68 documented visits to the ED, and 1 patient missed 91 scheduled clinic visits. Table 2 summarizes resource utilization in the high CT scan utilizer subgroup.
Parameter
Mean
Standard Deviation
Median
Range
Surgery clinic visits GI clinic visits ED visits Missed appointments Colonoscopy Small bowel series Outpatient CT
26.5 10.2 37.2 64.7 3 1.5 13
26.3 7.2 33.5 22.9 1.6 1 4.7
20.5 12.0 12 40.5 3 1 13
5–60 0–17 0–68 35–91 1–5 0–2 8–18
Abbreviations: CT, computed tomography; ED, emergency department; GI, gastrointestinal.
The other 59 patients had a mean of 1.4 outpatient CT scans during the 10-year study period. Twenty-four of 83 patients (29%) in the low CT scan utilizer group had CTs obtained in the ED. Of the 33.8% of patients diagnosed with chronic pain, 28.8% were using narcotics chronically, 37.2% had a psychiatric diagnosis, and 25.4% a functional disorder. The median number of ED visits was 1 in the low-utilizer cohort (Table 3). Univariate analysis revealed that patients in both the lowand high-scan utilizer groups were similar in age, number of GI clinic visits, number of colonoscopies, and number of small bowel series during the study period. However, frequent CT patients differed from low-scan utilizers in that the former had more cancelled or no-show appointments (P , 0.001), more surgery clinic visits (P , 0.001), and more ED visits (P , 0.001). Patients who underwent frequent CT scans were also more likely to have functional disorders (P , 0.016). There was a trend toward having a concomitant psychiatric diagnosis, though this failed to reach statistical significance (P = 0.055).
Discussion
We have shown that patients with Crohn’s disease who underwent frequent CT scan usage were statistically associated with increased functional disorder(s), more ED visits, and a greater number of surgery clinic visits in the study
Table 1. Resource Utilization in Patients Who Underwent Ileocolic Resection for Crohn’s Disease (N = 63)
Table 3. Characteristics of Low CT Scan Utilizers (N = 59)
Parameter
Mean
Standard Deviation
Median
Range
Parameter
Mean
Standard Deviation
Median
Range
Surgery clinic visits GI clinic visits ED visits Missed appointments Colonoscopy Small bowel series Outpatient CT
7.1 18.3 4.7 20.2 1.9 1.1 2.1
9.3 20 12.2 21.2 1.4 1.1 3.3
4 11 1 12 2 1 1
0–60 0–100 0–68 1–91 0–5 0–6 0–18
Surgery clinic visits GI clinic visits ED visits Missed appointments Colonoscopy Small bowel series Outpatient CT
5.8 18.9 2.5 6.4 1.8 1.1 1.4
5.5 20.5 4.9 17.6 1.3 1.1 1.5
4 11 1 11 2 1 2
0–26 0–100 0–26 1–86 0–5 0–6 0–5
Abbreviations: CT, computed tomography; ED, emergency department; GI, gastrointestinal.
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Abbreviations: CT, computed tomography; ED, emergency department; GI, gastrointestinal.
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Predictors of Excessive CT Use in Surgical Patients With Crohn’s Disease
population. In short, frequent imaging is often a surrogate for patients who seek, require, or otherwise consume vast amounts of other health care resources. The use of diagnostic CT scan in our patients was modest overall. The median number of CT scans per patient during the 10-year study period was only 1; but a small subset of patients underwent a remarkable number of CT scans and received significant exposure to ionizing radiation. As our study excluded inpatient CT scans, the actual number of examinations that the high-scan utilizing patients had during the study period was almost certainly even higher. Further, the study time period represents a relatively small fraction of the patient’s lifetime exposure to ionizing radiation. We chose not to consider imaging studies obtained during patient hospitalizations because such scans were not typically ordered to assess chronic symptoms, but to exclude a specific disease or surgery-related complication. Rather, in our study, we sought to understand the pattern and characteristics of “discretionary” CT scan usage by patients with Crohn’s disease. Many patients undergo multiple CT scans for diagnosis or monitoring of the status of infectious complications after surgery. Similarly, CT scans are often appropriately obtained to rule in or out the presence of an abscess before initiating biologic or immunomodulatory agents in patients admitted with an exacerbation of disease. Although clearly imperfect, we wanted to capture the use of CT scans in patients who were not in the immediate postoperative period or did not have a definable complication of Crohn’s disease. Mean cumulative radiation dose in patients with inflammatory bowel disease has been studied by others. Jaffe studied the organ doses in patients with Crohn’s disease and determined that abdominopelvic multidetector CT has an effective dose of 16.1 millisieverts (mSV).10 Patients with Crohn’s disease had a cumulative effective dose of 21.1 ± 19.5 mSV during an 8-year period. Similar to our study, approximately 7% of patients in Jaffe’s study were high-scan utilizers and had an estimated cumulative effective dose of . 50 mSV. Three percent of the patients with Crohn’s disease in that series had . 10 CT scans. Epidemiologic studies in human have demonstrated that radiation exposure ranging from 10 to 50 mSV of acute exposure and 50 to 100 mSV of protracted exposure correlates with increased rates of cancer.5 Another series evaluating radiation exposure in patients with inflammatory bowel disease, Peloquin et al9 reported that patients with Crohn’s disease had a median total effective dose of radiation of 26 mSV (range, 0–279) during an 8.90-year period; when adjusted for study length, the annual per patient median effective dose was 3.1 mSV.9 Overall, CT scans
accounted for approximately half of total effective radiation exposure, and other radiologic studies (eg, plain films, upper GI series, endoscopic retrograde cholangiopancreatography [ERCP], barium enema, and enteroclysis) composed the remainder. It was concluded that annualized ionizing radiation exposure in patients with Crohn’s disease is similar to background radiation exposure; however, again, Peloquin et al found a distinct patient subset that was exposed to greatly increased ionizing radiation. The patients in the subset, like the subgroup in our series, were potentially at an increased risk of developing a radiation-associated malignancy. High CT-scan utilizers in our series had a markedly greater number of visits to gastroenterologists, surgeons, and the ED, although they also cancelled or did not turn up for many scheduled appointments. Most of their CT scans were ordered during repetitive visits to the ED. Patients who are high scan utilizers are almost invariably on pain medications, and their symptoms also appear to “spill over” into other organ systems, as evidenced by their greater number of functional diagnoses. The profile seen with high CT scan utilizers in our study of patients with Crohn’s disease seems consistent with a group of patients seeking but perhaps not finding satisfactory answers for their symptoms and appears to be a reflection of their sense of a diminished quality of life. Patients with depression have been found to have their symptoms correlate with changes in the Crohn’s Disease Activity Index,11 suggesting that routine evaluation and treatment of depression may have an important role in modifying disease-related symptoms. Identifying patients who make and/or cancel many appointments and exhibit high global demand of the health care system may provide an opportunity for meaningful intervention, rather than simply ordering more tests, such as a CT scan. Of note, 1 study12 found that only a fraction of CT scans (28%) p erformed in patients with Crohn’s disease resulted in findings that altered medical or surgical management.12 Although it is not always easy to objectively define the utility of a CT scan in medical decision-making and we did not catalog the CT findings or calculate the Crohn’s Disease Activity Index,13–18 it was very clear in our review that the vast majority of reports described essentially the same findings over and over again, with little or no demonstrable effect on the patient treatment plan. In a study from our institution of surgical patients with slow transit constipation,19 the subgroup of patients with a history of sexual abuse were far more likely to require medical attention for continued abdominal symptomatology after colectomy.19 Patients with a history of sexual abuse
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also had greater numbers of functional diagnoses, more surgeries for functional disorders, and more psychiatric diagnoses. Clearly, many patient-specific factors, experiences, or attributes modify the subjective symptomatic outcomes after bowel surgery. We did not systematically explore the incidence of sexual abuse or other environmental stressors in our study patients with Crohn’s disease. It would seem that CT scans are ordered in some patients as a way of validating symptoms, despite a virtual certainty that symptoms will not be explicable by inflammatory changes or other abnormal findings. This was certainly the case in our study high CT scan utilizers, as scan after scan in the ED yielded similar results, almost never changing patient disease management. It must be recalled that patients with Crohn’s disease are already at greater risk of developing colorectal cancer20,21 and the effects of ionizing radiation could conceivably be synergistic or at least additive. Screening for and treating co-occurring depression is a reasonable and feasible intervention that may considerably reduce resource utilization associated with the management of patients with Crohn’s disease.22–27 Maximizing coping skills and adequate pharmacologic therapy may decrease radiation exposure and improve quality of life. Although it is true that substituting other imaging modalities, such as magnetic resonance imaging or magnetic resonance enterography, could reduce exposure to ionizing radiation,28,29 the underlying issues of overall patient resource utilization, expense, and poor symptom control would still persist. We believe that identifying patients with Crohn’s disease with high CT scan utilization, as well as frequent clinic or ED visits and cancellations, may provide an identifiable indicator of patients who should be screened and potentially treated for depression.
Study Limitations
Our study was limited by its small sample size and lack of geographic and ethnic diversity, which decreases generalizability as all enrolled patients were Vermont residents. The decision to exclude out-of-state residents and include only Vermonters to increase the probability of more complete follow-up can rightly be criticized, as many New York State residents had most or all of their follow-up at our institution, whereas many Vermonters did not. The follow-up is variable for the entire study population and limited to a median of 6 years. Further, it is certainly possible that study patients had CT scans at other institutions during the 10-year period of the study because study patients were young and potentially mobile. Undoubtedly, our study patients have had and/or likely will have many more CT scans during their lifetime. In addition, we excluded 98
CT scans performed within 30 days of surgery and those obtained after patient admission to the hospital. At best, our study provides a partial picture of CT usage for most patients with Crohn’s disease—but this was not our aim. Rather, our intent was to focus on the distinct subgroup of patients with Crohn’s disease with extraordinary CT scan utilization so that we might find opportunities to provide more cost effective care and improved quality of life for patients in this cohort, who are involved in so many encounters with the health care system. Similarly, visits with gastroenterologists at other institutions or to other EDs would not have been captured. As such, our data should be interpreted as the minimum number of such encounters, and the actual frequency of these visits is likely greater for this subpopulation of patients with Crohn’s disease.
Conclusion
In summary, we believe there is a small subset of patients with Crohn’s disease who undergo frequent CT scans and are potentially exposed to dangerous doses of ionizing radiation. This cohort uses considerable health care resources across the board, seeking relief of their symptoms typically without effective resolution. These patients characteristically have additional chronic complaints outside the GI tract and are often treated with chronic pain medication. Early recognition of this constellation of clinical attributes and health care utilization may provide an opportunity for more cost-effective intervention in this cohort of patients.
Conflict of Interest Statement
Whitney Young, MD, Neil Hyman, MD, and Turner Osler, MD, disclose no conflicts of interest. References
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© Postgraduate Medicine, Volume 125, Issue 6, November 2013, ISSN – 0032-5481, e-ISSN – 1941-9260 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.
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Predictors of Excessive CT Use in Surgical Patients With Crohn’s Disease 8. Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med. 2007;357(22):2277–2284. 9. Peloquin JM, Pardi DS, Sandborn WJ, et al. Diagnostic ionizing radiation exposure in a population-based cohort of patients with inflammatory bowel disease. Am J Gastroenterol. 2008;103(8):2015–2022. 10. Jaffe TA, Gaca AM, Delaney S, et al. Radiation doses from small-bowel follow-through and abdominopelvic MDCT in Crohn’s disease. Am J Roentgenol. 2007;189(5):1015–1022. 11. Mardini HE, Kip KE, Wilson JW. Crohn’s disease: a two-year prospective study of the association between psychological distress and disease activity. Dig Dis Sci. 2004;49(3):492–497. 12. Fishman EK, Wolf EJ, Jones BJ, et al. CT evaluation of Crohn’s disease: effect on patient management. Am J Roentgenol. 1987; 148(3):537–540. 13. Best WR, Becktel JM, Singleton JW, Kern F Jr. Development of a Crohn’s disease activity index. National Cooperative Crohn’s Disease Study. Gastroenterology. 1976;70(3):439–444. 14. Best WR. Becktel JM, Singleton JW. Rederived values of the eight coefficients of the Crohn’s Disease Activity Index (CDAI). Gastroenterology. 1979;77(4 Pt 2):843–846. 15. Sandborn WJ, Feagan BG, Hanauer SB, et al. A review of activity indices and efficacy endpoints for clinical trials of medical therapy in adults with Crohn’s disease. Gastroenterology. 2002;122(2):512–530. 16. Xiao Li F, Sutherland LR. Assessing disease activity and disease activity indices for inflammatory bowel disease. Curr Gastroenterol Rep. 2002;4(6):490–496. 17. Sostegni R, Daperno M, Scaglione N, Lavagna A, Rocca R, Pera A. Review article: Crohn’s disease: monitoring disease activity. Aliment Pharmacol Ther. 2003;17(Suppl 2):11–17. 18. Yoshida EM. The Crohn’s Disease Activity Index, its derivatives and the Inflammatory Bowel Disease Questionnaire: a review of instruments to assess Crohn’s disease. Can J Gastroenterol. 1999;13(1):65–73. 19. O’Brien S, Hyman N, Osler T, Rabinowitz T. Sexual abuse: a strong predictor of outcomes after colectomy for slow-transit constipation. Dis Colon Rectum. 2009;52(11):1844–1847.
20. Maykel JA, Hagerman G, Mellgren AF, et al. Crohn’s colitis: the incidence of dysplasia and adenocarcinoma in surgical patients. Dis Colon Rectum. 2006;49(7):950–957. 21. Friedman S, Rubin PH, Bodian C, et al. Screening and surveillance colonoscopy in chronic Crohn’s colitis. Gastroenterology. 2001;120(4):820–826. 22. Zhang CK, Hewett J, Hemming J, et al. The influence of depression on quality of life in patients with inflammatory bowel disease. Inflamm Bowel Dis. 2013;19(8):1732–1739. 23. Nurmi E, Haapamäki J, Paavilainen E, Rantanen A, Hillilä M, Arkkila P. The burden of inflammatory bowel disease on health care utilization and quality of life. Scand J Gastroenterol. 2013;48(1):51–57. 24. Umanskiy K, Fichera A. Health related quality of life in inflammatory bowel disease: the impact of surgical therapy. World J Gastroenterol. 2010;16(40):5024–5034. 25. Gibson PR, Weston AR, Shann A, et al. Relationship between disease severity, quality of life and health related resource use in a cross-section of Australian patients with Crohn’s disease. J Gastroenterol Hepatol. 2007;22(8):1306–1312. 26. Longobardi T, Walker JR, Graff LA, Bernstein CN. Health service utilization in IBD: comparison of self-report and administrative data. BMC Health Serv Res. 2011;11:137. 27. Longobardi T, Bernstein CN. Health care resource utilization in inflammatory bowel disease. Clin Gastroenterol Hepatol. 2006;49(6): 731–743. 28. Low RN, Francis IR, Politoske D, et al. Crohn’s disease evaluation: comparison of contrast—enhanced MR imaging and single-phase helical CT scanning. J Magn Reson Imaging. 2000;11(2):127–135. 29. Sempere GA, Sanjuan VM, Chulia EM, et al. MRI evaluation of inflammatory activity in Crohn’s disease. Am J Roentgenol. 2005; 184(6):1829–1835.
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Predictors of Excessive CT Scan Use in a Surgical Cohort of Patients With Crohn's Disease Whitney Young MD, Neil Hyman MD & Turner Osier MD To cite this article: Whitney Young MD, Neil Hyman MD & Turner Osier MD (2013) Predictors of Excessive CT Scan Use in a Surgical Cohort of Patients With Crohn's Disease, Postgraduate Medicine, 125:6, 94-99 To link to this article: http://dx.doi.org/10.3810/pgm.2013.11.2716
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C L I N I C A L F E AT U R E S
Predictors of Excessive CT Scan Use in a Surgical Cohort of Patients With Crohn’s Disease
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DOI: 10.3810/pgm.2013.11.2716
Whitney Young, MD 1 Neil Hyman, MD 1 Turner Osler, MD 1 Department of Surgery, University of Vermont College of Medicine, Burlington, VT 1
Abstract
Background: Patients with Crohn’s disease typically undergo computed tomography (CT) scans periodically over the course of their chronic disorder, requiring only modest doses of ionizing radiation. However, previous studies have suggested there is a subgroup of patients with Crohn’s disease who undergo frequent CT scans with an associated increase in health care expenditures and possible overexposure to radiation, potentially placing such patients at increased risk for cancer. The aim of our study was to characterize and define this potentially vulnerable cohort using a relatively homogeneous surgical population. Methods: Consecutive patients who underwent ileocolic resection for Crohn’s disease from January 2000 to September 2010 at an academic medical center were identified from a prospectively maintained database. Only patient CT scans remote from surgery or hospitalization were considered in the analysis. The number of outpatient CT scans, physician visits, and coexisting psychiatric and functional diagnoses were recorded from retrospective chart review. Patients who were considered high CT scan utilizers were compared with patients who were low utilizers. Results: Sixty-three patients underwent 126 CT scans during the study period, however, 4 of the patients accounted for 52 (41%) of the studies. Compared with the overall study population, the subset of 4 patients (high utilizers) had a median of 66 clinic visits (P , 0.001) and 40 emergency department visits (P , 0.001). All 4 patients were on chronic narcotic medication, and only 1 did not have a concomitant functional disorder. Missed appointments and the absence of prescribed antidepressants were common among patients with high CT use. Conclusions: Although use of CT appears moderate in surgical patients with Crohn’s disease overall, there is a subset of patients with chronic pain and psychiatric diagnoses, who frequently miss appointments, and account for a markedly disproportionate number of scans performed. Interestingly, use of antidepressants in patients with Crohn’s disease was strongly associated with fewer scans, suggesting an opportunity for therapeutic intervention. Keywords: computed tomography scan; Crohn’s disease; surgery; radiation
Introduction
Correspondence: Neil Hyman, MD, Department of Surgery, University of Vermont College of Medicine, Fletcher 465, Burlington, VT 05401. Tel: 802-847-2194 Fax: 802-846-5579 E-mail: [email protected]
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Patients with Crohn’s disease frequently require radiologic imaging studies to evaluate abdominal symptomatology, often incurring considerable resource costs, while being exposed to significant ionizing radiation.1–3 As Crohn’s disease is a chronic and relapsing condition that often affects young people,4 the cumulative effects may be substantial over the course of a lifetime. Exposure to high levels of ionizing radiation exposure is linked to an increased risk for developing malignancy.5,6 The use of computed tomography (CT) imaging has substantially increased in recent years,7,8 therefore, justifiable concern has been expressed about the risk of radiation-induced carcinoma in patients with Crohn’s disease.
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Predictors of Excessive CT Use in Surgical Patients With Crohn’s Disease
Previous studies have shown that a subset of patients with Crohn’s disease are exposed to considerably higher doses of radiation owing to the frequency of radiologic evaluations.9,10 It has been our experience that these are usually patients whose abdominal symptoms cannot be readily ascribed to disease-related activity, but they still undergo repetitive imaging studies that rarely demonstrate new findings or change patient management regimens. Patients with Crohn’s disease usually have a relationship with their primary care provider, a gastroenterologist, surgeon, and potentially, a host of emergency department (ED) physicians, so there are many opportunities for redundant care. It seems evident that new or different strategies are required to improve the effectiveness of care and outcomes in this high-use cohort. The aim of our study was to characterize the subgroup of patients with Crohn’s disease who undergo frequent CT scans in the hope that recognition of these patients might lead to more fruitful approaches to disease management, or, at least prevent excessive use of CT scans in this subpopulation. On the basis of clinical observation, we hypothesized that of those patients with Crohn’s disease, patients who were frequent CT scan users would also be characterized by markedly greater overall resource utilization, including more ED visits, more cancelled or no-show appointments, and have increased functional and psychiatric diagnoses.
Methods
All Vermont residents aged .18 years, undergoing elective ileocolic resection for histopathologically proven Crohn’s disease at Fletcher Allen Health Care, the teaching hospital of the University of Vermont College of Medicine (Burlington, VT), between January 2000 and September 2010, were identified from a prospectively maintained surgical complication database. A cohort of patients with terminal ileal disease alone or in combination with right colon involvement was chosen to enhance homogeneity and assure that the diagnosis of Crohn’s disease was based on tissue diagnosis. Patients who lived out of state, were institutionalized, cognitively impaired, or aged , 18 years were excluded because they did not necessarily have routine follow-up care for disease management at our institution. Fletcher Allen Healthcare is a tertiary care referral center serving Vermont and upstate New York. Approximately 40% of patients who undergo surgery for Crohn’s disease at our institution are New York State residents who are typically cared for by primary care physicians and gastroenterologists back home. Demographic data collected included patient age, sex, ethnicity, town or city of residence in Vermont, and the
duration of diagnosis of Crohn’s disease before surgery. The number of visits to the gastroenterology outpatient clinic, surgery outpatient clinic, and the ED for Crohn’s disease-related symptoms and management was recorded. The frequency of cancelled and no-show appointments was collected based on the electronic appointment scheduling system records. The number of other diagnostic studies, such as colonoscopies and small bowel series for the study duration were determined by review of patient radiologic and endoscopy folders. The outpatient clinic records and problem lists were evaluated for chronic use of narcotics, specific non-narcotic pain medications (such as amitriptyline, pregabalin, and gabapentin), and treatment with antidepressants (defined as $ 6 months of continuous use). Psychiatric diagnoses, including major depression, schizophrenia, personality disorder, or somatoform disorder were recorded. In addition, concomitant diagnoses of chronic pain syndrome(s) and functional disorders were assessed from the medical record; these included chronic pelvic pain, neck pain, back pain, jaw pain, headaches, or fibromyalgia. The CT scans were classified as either in-patient or outpatient based on the patient status at the time of the imaging and hospital admission dates as documented in the electronic or paper medical records. Patients with Crohn’s disease who were not admitted to the hospital after CT scans were performed were considered to have had outpatient studies. To avoid the confounding contribution of medical and surgical complications to the analysis, in-patient CT scans and those performed within 30 days of surgery were excluded. The goal was to exclude all scans performed to assess, track, or manage postoperative complications so that only CT scans performed to e valuate symptoms remote from surgery would be included. Similarly, we excluded all other in-patient CT scans because they were usually obtained to exclude a disease-specific complication before a change in medical management during symptomatic exacerbation requiring hospital admission (eg, to rule out an abscess before initiating treatment with steroids or a biologic). For the purpose of comparative analysis, 2 groups were defined: patients with $ 8 outpatient CT scans during the 10-year study period were considered frequent CT scan utilizers and were compared with patients who were low CT scan utilizers, having undergone , 8 scans. Several patient characteristics were compared between the 2 groups; because these characteristics were skewed in their distributions, the Mann–Whitney–Wilcoxon test was used throughout. Our study was approved by the Institutional Review Board of the University of Vermont College of Medicine.
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Young et al
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Results
Table 2. Characteristics of High CT Scan Utilizers (N = 4)
Sixty-three patients satisfied inclusion criteria for the study. Median patient age was 49 years (range, 24–81 years), and 40 patients were women (63.4%). The length of follow-up ranged from 2 to 11 years (mean, 6.2 years). All patients carried the diagnosis of Crohn’s disease for $ 1 year before surgery and had histopathologic confirmation of the diagnosis based on review of the surgical specimen. Twenty-four patients (38%) had a concomitant diagnosis of a chronic pain syndrome; 21 patients (33%) were on chronic narcotics; 10 patients (15.8%) took non-narcotic pain medication, such as gabapentin, on a chronic basis; and 15 patients (23.8%) regularly used antidepressants. Twenty five patients (39.5%) had a psychiatric diagnosis, usually depression, and 18 patients (28.5%) had $ 1 functional diagnosis. The number of patient arrived and missed physician visits and common diagnostic assessments are listed in Table 1. Although the number of evaluations and physician visits for most patients is generally modest, there is a remarkable range in our total study patient population. For example, the median number of surgery clinic visits during 10 years was 4, but the range was 0 to 60. Similarly, for gastrointestinal (GI) clinic visits, the median was 11, with a range from 0 to 100. The number of CT scans per patient ranged from 0 to 18. The high CT scan utilizers (n = 4) included 2 men and 2 women patients. The 4 patients had 8, 10, 16, and 18 CT scans, respectively, during the study period. Forty of 52 CT scans (77%) in this patient group were obtained in the ED. All 4 patients had a diagnosis of chronic pain syndrome, all were taking narcotics chronically, 3 had a history of depression, and 3 had $ 1 functional disorders. Two patients were taking antidepressants. One of these patients had 68 documented visits to the ED, and 1 patient missed 91 scheduled clinic visits. Table 2 summarizes resource utilization in the high CT scan utilizer subgroup.
Parameter
Mean
Standard Deviation
Median
Range
Surgery clinic visits GI clinic visits ED visits Missed appointments Colonoscopy Small bowel series Outpatient CT
26.5 10.2 37.2 64.7 3 1.5 13
26.3 7.2 33.5 22.9 1.6 1 4.7
20.5 12.0 12 40.5 3 1 13
5–60 0–17 0–68 35–91 1–5 0–2 8–18
Abbreviations: CT, computed tomography; ED, emergency department; GI, gastrointestinal.
The other 59 patients had a mean of 1.4 outpatient CT scans during the 10-year study period. Twenty-four of 83 patients (29%) in the low CT scan utilizer group had CTs obtained in the ED. Of the 33.8% of patients diagnosed with chronic pain, 28.8% were using narcotics chronically, 37.2% had a psychiatric diagnosis, and 25.4% a functional disorder. The median number of ED visits was 1 in the low-utilizer cohort (Table 3). Univariate analysis revealed that patients in both the lowand high-scan utilizer groups were similar in age, number of GI clinic visits, number of colonoscopies, and number of small bowel series during the study period. However, frequent CT patients differed from low-scan utilizers in that the former had more cancelled or no-show appointments (P , 0.001), more surgery clinic visits (P , 0.001), and more ED visits (P , 0.001). Patients who underwent frequent CT scans were also more likely to have functional disorders (P , 0.016). There was a trend toward having a concomitant psychiatric diagnosis, though this failed to reach statistical significance (P = 0.055).
Discussion
We have shown that patients with Crohn’s disease who underwent frequent CT scan usage were statistically associated with increased functional disorder(s), more ED visits, and a greater number of surgery clinic visits in the study
Table 1. Resource Utilization in Patients Who Underwent Ileocolic Resection for Crohn’s Disease (N = 63)
Table 3. Characteristics of Low CT Scan Utilizers (N = 59)
Parameter
Mean
Standard Deviation
Median
Range
Parameter
Mean
Standard Deviation
Median
Range
Surgery clinic visits GI clinic visits ED visits Missed appointments Colonoscopy Small bowel series Outpatient CT
7.1 18.3 4.7 20.2 1.9 1.1 2.1
9.3 20 12.2 21.2 1.4 1.1 3.3
4 11 1 12 2 1 1
0–60 0–100 0–68 1–91 0–5 0–6 0–18
Surgery clinic visits GI clinic visits ED visits Missed appointments Colonoscopy Small bowel series Outpatient CT
5.8 18.9 2.5 6.4 1.8 1.1 1.4
5.5 20.5 4.9 17.6 1.3 1.1 1.5
4 11 1 11 2 1 2
0–26 0–100 0–26 1–86 0–5 0–6 0–5
Abbreviations: CT, computed tomography; ED, emergency department; GI, gastrointestinal.
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Abbreviations: CT, computed tomography; ED, emergency department; GI, gastrointestinal.
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Predictors of Excessive CT Use in Surgical Patients With Crohn’s Disease
population. In short, frequent imaging is often a surrogate for patients who seek, require, or otherwise consume vast amounts of other health care resources. The use of diagnostic CT scan in our patients was modest overall. The median number of CT scans per patient during the 10-year study period was only 1; but a small subset of patients underwent a remarkable number of CT scans and received significant exposure to ionizing radiation. As our study excluded inpatient CT scans, the actual number of examinations that the high-scan utilizing patients had during the study period was almost certainly even higher. Further, the study time period represents a relatively small fraction of the patient’s lifetime exposure to ionizing radiation. We chose not to consider imaging studies obtained during patient hospitalizations because such scans were not typically ordered to assess chronic symptoms, but to exclude a specific disease or surgery-related complication. Rather, in our study, we sought to understand the pattern and characteristics of “discretionary” CT scan usage by patients with Crohn’s disease. Many patients undergo multiple CT scans for diagnosis or monitoring of the status of infectious complications after surgery. Similarly, CT scans are often appropriately obtained to rule in or out the presence of an abscess before initiating biologic or immunomodulatory agents in patients admitted with an exacerbation of disease. Although clearly imperfect, we wanted to capture the use of CT scans in patients who were not in the immediate postoperative period or did not have a definable complication of Crohn’s disease. Mean cumulative radiation dose in patients with inflammatory bowel disease has been studied by others. Jaffe studied the organ doses in patients with Crohn’s disease and determined that abdominopelvic multidetector CT has an effective dose of 16.1 millisieverts (mSV).10 Patients with Crohn’s disease had a cumulative effective dose of 21.1 ± 19.5 mSV during an 8-year period. Similar to our study, approximately 7% of patients in Jaffe’s study were high-scan utilizers and had an estimated cumulative effective dose of . 50 mSV. Three percent of the patients with Crohn’s disease in that series had . 10 CT scans. Epidemiologic studies in human have demonstrated that radiation exposure ranging from 10 to 50 mSV of acute exposure and 50 to 100 mSV of protracted exposure correlates with increased rates of cancer.5 Another series evaluating radiation exposure in patients with inflammatory bowel disease, Peloquin et al9 reported that patients with Crohn’s disease had a median total effective dose of radiation of 26 mSV (range, 0–279) during an 8.90-year period; when adjusted for study length, the annual per patient median effective dose was 3.1 mSV.9 Overall, CT scans
accounted for approximately half of total effective radiation exposure, and other radiologic studies (eg, plain films, upper GI series, endoscopic retrograde cholangiopancreatography [ERCP], barium enema, and enteroclysis) composed the remainder. It was concluded that annualized ionizing radiation exposure in patients with Crohn’s disease is similar to background radiation exposure; however, again, Peloquin et al found a distinct patient subset that was exposed to greatly increased ionizing radiation. The patients in the subset, like the subgroup in our series, were potentially at an increased risk of developing a radiation-associated malignancy. High CT-scan utilizers in our series had a markedly greater number of visits to gastroenterologists, surgeons, and the ED, although they also cancelled or did not turn up for many scheduled appointments. Most of their CT scans were ordered during repetitive visits to the ED. Patients who are high scan utilizers are almost invariably on pain medications, and their symptoms also appear to “spill over” into other organ systems, as evidenced by their greater number of functional diagnoses. The profile seen with high CT scan utilizers in our study of patients with Crohn’s disease seems consistent with a group of patients seeking but perhaps not finding satisfactory answers for their symptoms and appears to be a reflection of their sense of a diminished quality of life. Patients with depression have been found to have their symptoms correlate with changes in the Crohn’s Disease Activity Index,11 suggesting that routine evaluation and treatment of depression may have an important role in modifying disease-related symptoms. Identifying patients who make and/or cancel many appointments and exhibit high global demand of the health care system may provide an opportunity for meaningful intervention, rather than simply ordering more tests, such as a CT scan. Of note, 1 study12 found that only a fraction of CT scans (28%) p erformed in patients with Crohn’s disease resulted in findings that altered medical or surgical management.12 Although it is not always easy to objectively define the utility of a CT scan in medical decision-making and we did not catalog the CT findings or calculate the Crohn’s Disease Activity Index,13–18 it was very clear in our review that the vast majority of reports described essentially the same findings over and over again, with little or no demonstrable effect on the patient treatment plan. In a study from our institution of surgical patients with slow transit constipation,19 the subgroup of patients with a history of sexual abuse were far more likely to require medical attention for continued abdominal symptomatology after colectomy.19 Patients with a history of sexual abuse
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Young et al
also had greater numbers of functional diagnoses, more surgeries for functional disorders, and more psychiatric diagnoses. Clearly, many patient-specific factors, experiences, or attributes modify the subjective symptomatic outcomes after bowel surgery. We did not systematically explore the incidence of sexual abuse or other environmental stressors in our study patients with Crohn’s disease. It would seem that CT scans are ordered in some patients as a way of validating symptoms, despite a virtual certainty that symptoms will not be explicable by inflammatory changes or other abnormal findings. This was certainly the case in our study high CT scan utilizers, as scan after scan in the ED yielded similar results, almost never changing patient disease management. It must be recalled that patients with Crohn’s disease are already at greater risk of developing colorectal cancer20,21 and the effects of ionizing radiation could conceivably be synergistic or at least additive. Screening for and treating co-occurring depression is a reasonable and feasible intervention that may considerably reduce resource utilization associated with the management of patients with Crohn’s disease.22–27 Maximizing coping skills and adequate pharmacologic therapy may decrease radiation exposure and improve quality of life. Although it is true that substituting other imaging modalities, such as magnetic resonance imaging or magnetic resonance enterography, could reduce exposure to ionizing radiation,28,29 the underlying issues of overall patient resource utilization, expense, and poor symptom control would still persist. We believe that identifying patients with Crohn’s disease with high CT scan utilization, as well as frequent clinic or ED visits and cancellations, may provide an identifiable indicator of patients who should be screened and potentially treated for depression.
Study Limitations
Our study was limited by its small sample size and lack of geographic and ethnic diversity, which decreases generalizability as all enrolled patients were Vermont residents. The decision to exclude out-of-state residents and include only Vermonters to increase the probability of more complete follow-up can rightly be criticized, as many New York State residents had most or all of their follow-up at our institution, whereas many Vermonters did not. The follow-up is variable for the entire study population and limited to a median of 6 years. Further, it is certainly possible that study patients had CT scans at other institutions during the 10-year period of the study because study patients were young and potentially mobile. Undoubtedly, our study patients have had and/or likely will have many more CT scans during their lifetime. In addition, we excluded 98
CT scans performed within 30 days of surgery and those obtained after patient admission to the hospital. At best, our study provides a partial picture of CT usage for most patients with Crohn’s disease—but this was not our aim. Rather, our intent was to focus on the distinct subgroup of patients with Crohn’s disease with extraordinary CT scan utilization so that we might find opportunities to provide more cost effective care and improved quality of life for patients in this cohort, who are involved in so many encounters with the health care system. Similarly, visits with gastroenterologists at other institutions or to other EDs would not have been captured. As such, our data should be interpreted as the minimum number of such encounters, and the actual frequency of these visits is likely greater for this subpopulation of patients with Crohn’s disease.
Conclusion
In summary, we believe there is a small subset of patients with Crohn’s disease who undergo frequent CT scans and are potentially exposed to dangerous doses of ionizing radiation. This cohort uses considerable health care resources across the board, seeking relief of their symptoms typically without effective resolution. These patients characteristically have additional chronic complaints outside the GI tract and are often treated with chronic pain medication. Early recognition of this constellation of clinical attributes and health care utilization may provide an opportunity for more cost-effective intervention in this cohort of patients.
Conflict of Interest Statement
Whitney Young, MD, Neil Hyman, MD, and Turner Osler, MD, disclose no conflicts of interest. References
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20. Maykel JA, Hagerman G, Mellgren AF, et al. Crohn’s colitis: the incidence of dysplasia and adenocarcinoma in surgical patients. Dis Colon Rectum. 2006;49(7):950–957. 21. Friedman S, Rubin PH, Bodian C, et al. Screening and surveillance colonoscopy in chronic Crohn’s colitis. Gastroenterology. 2001;120(4):820–826. 22. Zhang CK, Hewett J, Hemming J, et al. The influence of depression on quality of life in patients with inflammatory bowel disease. Inflamm Bowel Dis. 2013;19(8):1732–1739. 23. Nurmi E, Haapamäki J, Paavilainen E, Rantanen A, Hillilä M, Arkkila P. The burden of inflammatory bowel disease on health care utilization and quality of life. Scand J Gastroenterol. 2013;48(1):51–57. 24. Umanskiy K, Fichera A. Health related quality of life in inflammatory bowel disease: the impact of surgical therapy. World J Gastroenterol. 2010;16(40):5024–5034. 25. Gibson PR, Weston AR, Shann A, et al. Relationship between disease severity, quality of life and health related resource use in a cross-section of Australian patients with Crohn’s disease. J Gastroenterol Hepatol. 2007;22(8):1306–1312. 26. Longobardi T, Walker JR, Graff LA, Bernstein CN. Health service utilization in IBD: comparison of self-report and administrative data. BMC Health Serv Res. 2011;11:137. 27. Longobardi T, Bernstein CN. Health care resource utilization in inflammatory bowel disease. Clin Gastroenterol Hepatol. 2006;49(6): 731–743. 28. Low RN, Francis IR, Politoske D, et al. Crohn’s disease evaluation: comparison of contrast—enhanced MR imaging and single-phase helical CT scanning. J Magn Reson Imaging. 2000;11(2):127–135. 29. Sempere GA, Sanjuan VM, Chulia EM, et al. MRI evaluation of inflammatory activity in Crohn’s disease. Am J Roentgenol. 2005; 184(6):1829–1835.
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