Plain x-ray remains commonly used in initial imaging of adults with maxillofacial trauma, despite clear guidelines favoring CT, according to a study published February 17 in JAMA Network Open.
In an analysis of information from 281,421 patients in a U.S. national commercial claims database, 72,125 (26%) received low-value plain x-rays of the nose, face, or orbit as the initial imaging, noted first author Gordon Wong, MBBS, of the University of Michigan Medical School in Ann Arbor, and colleagues.
“Targeted interventions to reduce low-value imaging may improve diagnostic accuracy, reduce unnecessary costs, and advance value-based care,” the group wrote.
Facial trauma is one of the most common reasons for emergency department visits. Low-sensitivity x-ray imaging in these patients offers limited diagnostic value and often fails to detect clinically significant injuries that would be identified by CT, the authors noted. Both the American College of Radiology (ACR) and the American Society of Plastic Surgeons recommend against the routine use of x-ray in maxillofacial trauma evaluation, they added.
Nonetheless, plain x-ray remains in use, and in this study, the investigators aimed to inform efforts to reduce low-value care for maxillofacial trauma and promote evidence-based imaging practices.
The researchers conducted a retrospective cohort study using data from the Merative MarketScan Commercial Claims and Encounters Database from January 2013 to December 2022. The analysis included 281,421 adult patients (mean age, 38.9) with facial trauma who received either a plain x-ray (nose, face, or orbit) or CT of the face or orbit within seven days of diagnosis.
According to the results, one in four patients received low-value plain x-ray versus CT as their initial imaging study. Although plain x-ray use declined by nearly half over the nine-year study period, its continued use had measurable consequences, with 5.5% of plain x-ray recipients requiring subsequent CT and 7.6% of patients without an initial fracture diagnosis experiencing a diagnostic delay of more than three days, Wong and colleagues reported.
In addition, women were 50% more likely than men to receive a plain x-ray, and urgent care settings had a 76% higher x-ray use than office-based settings.
“These findings underscore a persistent gap between evidence-based practice and actual clinical imaging patterns in facial trauma care,” the researchers wrote.
While the gradual decline of the use of x-ray during the study period demonstrates meaningful progress toward value-based imaging, as CT becomes more accessible, the adoption of guideline-concordant care must be prioritized, the group wrote.
“Targeted interventions are needed: streamlined CT referral pathways for urgent care settings, embedded decision-support tools in electronic health record systems, and cross-specialty education on facial trauma imaging standards,” the team suggested.
In an accompanying editorial, Chao Azad, MD, and Aviram Giladi, MD, of MedStar Union Memorial Hospital in Baltimore, MD, wrote that by quantifying variations in care, the study makes an important contribution to the existing literature on clinical practice guidelines (CPGs), specifically on gaps between CPGs and practice.
“It represents a meaningful opportunity for advancing value-based care,” they wrote.
The full study can be found here.