Balancing Access and Appropriateness in CT Angiography Use in the Emergency Department

Prasad et al 1 present a timely and thought-provoking retrospective study examining trends in CT angiography (CTA) utilization for gastrointestinal bleeding (GIB) in the emergency department (ED) over a 7-year period at a major academic center.Their findings show a 9.6-fold increase in the annual number of GIB-related CTA studies between 2017 and 2023, but with a marked decline in diagnostic yield-positivity rates dropped from 20.0% to just 6.3%.These data raise fundamental questions about the balance between diagnostic access and appropriateness in contemporary emergency medicine.CTA is a cornerstone imaging modality in the evaluation of suspected acute GIB.Its high sensitivity and specificity, combined with widespread availability and rapid acquisition times, have cemented its role in initial ED assessment, particularly for patients who are hemodynamically unstable or exhibit overt signs of bleeding.Indeed, both the American College of Gastroenterology and the Society of Abdominal Radiology endorse CTA as a first-line approach in such settings. 2Yet, Prasad et al 1 reveals that despite these recommendations, CTA is increasingly being used in broader, often lower-yield scenarios.The observed divergence between the increasing utilization of emergency care services and the concurrent decrease in diagnostic yield likely stems from a confluence of factors exerting pressure on the current system.Understanding these converging pressures is crucial for addressing the challenges facing emergency departments and optimizing the delivery of timely and effective care.Clinical uncertainty, medico-legal concerns, and the imperative to act decisively in crowded EDs likely contribute to a low threshold for imaging.Moreover, subtle presentations-such as anemia without overt bleeding, chronic heme-positive stools, or nonspecific abdominal pain-may prompt ordering of CTA even in the absence of high-risk features.Importantly, as the study shows, older patients were more likely to have positive results, suggesting that age-stratified decision pathways may enhance imaging efficiency.Overuse of imaging is not a benign phenomenon.In addition to exposing patients to radiation and contrast media, excessive CTA orders strain radiologic services, increase interpretation burden, and may contribute to ED throughput delays.In a broader sense, it risks undermining the valuebased care framework by diluting the clinical utility of a high-yield diagnostic tool.Prior studies across various clinical domains have documented similar trends of imaging overutilization with minimal clinical benefit and potential for downstream harm. 3,4 address this, several strategies should be considered.First, implementing clinical decisionsupport tools at the point of order entry could guide providers to utilize evidence-based criteria for CTA selection.Second, employing GIB-specific risk scores, such as the Glasgow-Blatchford or Oakland scores, may help identify patients with a low probability of active bleeding, allowing for observation or alternative diagnostic approaches.Lastly, fostering multidisciplinary collaboration among emergency medicine, radiology, and gastroenterology is crucial for developing consensus protocols tailored to local resources and expertise.Crucially, the goal is not to limit access to lifesaving diagnostics but to ensure that access is thoughtful and targeted.In certain high-acuity settings, rapid CTA remains indispensable for guiding endoscopic or interventional therapy. 5However, a patient presenting with vague symptoms and +