PoCUS-first versus CT-only for non-traumatic abdominal pain: a propensity score-weighted cohort study on ED resource utilization

Point-of-care ultrasound (PoCUS) may reduce emergency department (ED) length of stay (LOS) for selected abdominal diagnoses, but its role in undifferentiated, non-traumatic abdominal pain remains uncertain. This study compared PoCUS-first and CT-only strategies, evaluating associations with resource use and clinical outcomes in adult ED patients. This propensity score-weighted cohort study included adults (≥ 18 years) presenting with non-traumatic abdominal pain to the ED of a tertiary medical center in Taiwan between January 2021 and December 2023. Patients transferred or discharged against medical advice from other facilities were excluded. Encounters were classified as PoCUS-first (PoCUS alone and followed by CT) or CT-only. Primary outcomes were ED LOS and costs; secondary outcomes were unscheduled return visit (URV), hospital LOS, total costs, ICU admission, and in-hospital mortality. Multivariate regression and inverse probability of treatment weighting (IPTW) adjusted for baseline differences. Among 26,403 index ED visits, 67.5% received PoCUS‑first evaluation and 32.5% underwent CT only. After adjustment, PoCUS‑first was associated with substantially shorter ED LOS (ratio of means 0.53, 95% CI 0.52-0.54; 47% reduction), lower ED costs (0.52, 95% CI 0.51-0.53; 48% reduction), fewer consultations, and reduced admission rates. In patients discharged at the index visit (n = 17,390), PoCUS‑first was similarly linked to shorter LOS (0.61, 95% CI 0.60-0.62; 39% reduction), markedly lower costs (0.47, 95% CI 0.46-0.47; 53% reduction), and decreased odds of unscheduled return visits (OR 0.82, 95% CI 0.69-0.96), without an increase in adverse outcomes. For patients later admitted after a return visit, PoCUS‑first encounters were characterized by lower resource use during the index ED visit, with no evidence of prolonged subsequent care or safety concerns. A PoCUS‑first strategy, used for initial risk stratification, was associated with greater ED efficiency and more judicious resource use without compromising safety. However, the observed reduction in ED LOS may partly reflect local workflow and in‑house processes, and residual confounding cannot be excluded. Confirmation in prospective, multicenter studies is warranted.