Quantity Matters: Impact of Provider-in-Triage Deployment on Advanced Imaging Utilization

Quantity Matters: Impact of Provider-in-Triage Deployment on Advanced Imaging Utilization

Authors: Thom C, Spirek B, Mullins C, Moak J
Journal: American Journal of Emergency Medicine, July 2026

Conclusions:

  • Implementation of a provider-in-triage (PIT) split-flow model was associated with a significant increase in advanced imaging utilization, especially CT.

  • Among abdominal pain patients, PIT exposure was independently associated with higher CT use.

  • CT positivity was lower among abdominal pain patients exposed to PIT, suggesting possible over-imaging or lower-threshold imaging when decisions are made earlier in the visit.

  • Practical takeaway: PIT may improve front-end throughput, but it can also increase downstream resource use if imaging decisions are made before a complete evaluation, reassessment, or lab results are available.

Practice Takeaways:

  • PIT can be operationally attractive, but this study suggests it may increase CT utilization per visit, not just accelerate care.

  • For abdominal pain, earlier clinician contact may lower the threshold to order CT before labs, serial exams, analgesic response, or a more complete differential has matured.

  • Lower CT positivity in the PIT cohort is the key signal: more scans were being ordered, but a smaller proportion were positive.

  • EDs using PIT should track not only door-to-provider and LWBS metrics, but also:

    • CTs per 100 visits

    • CT positivity rate

    • CT use by chief complaint

    • Time from arrival to CT order

    • Imaging ordered before lab results

    • Downstream LOS and admission impact

  • PIT protocols may benefit from guardrails, especially for abdominal pain:

    • Use agreed-upon imaging criteria.

    • Encourage rapid analgesia/antiemetics and reassessment when appropriate.

    • Avoid CT orders based solely on chief complaint unless red flags are present.

    • Build feedback dashboards comparing individual and shift-level imaging yield.

  • This is observational and single-center, so causation is not proven. But it is a useful warning that front-end process redesign can shift burden to radiology and increase low-yield imaging

Results:

  • Setting: Single tertiary academic ED.

  • Design: 18 months before vs 18 months after PIT implementation in July 2023.

  • Adult ED visits:

    • Pre-PIT: 76,731

    • PIT period: 89,105

  • CT utilization increased:

    • Pre-PIT: 0.36 CTs per ED visit

    • PIT period: 0.49 CTs per ED visit

    • Adjusted absolute increase: +0.135 CTs per visit; p < 0.001

  • Smaller increases were also seen in:

    • MRI

    • Radiology-performed ultrasound

  • POCUS showed a nonsignificant decrease.

  • In the 2024 abdominal pain subgroup:

    • PIT exposure was independently associated with increased CT use:

      • OR 1.27; 95% CI 1.01–1.60

    • CT positivity was lower with PIT:

      • PIT: 38.7%

      • No PIT: 46.9%

      • Absolute difference: 8.2%

      • p = 0.03

Methods:

  • Single-center retrospective study at a tertiary academic ED.

  • Evaluated advanced imaging before and after implementation of a PIT split-flow model.

  • Advanced imaging utilization was analyzed using regression adjusted for:

    • Admission proportion

    • Emergency Severity Index score

  • A separate 2024 abdominal pain analysis compared PIT-exposed vs non-PIT patients.

  • Abdominal pain CT utilization models adjusted for:

    • Age

    • Sex

    • Race

    • Admission disposition

  • CT positivity rates were compared between PIT and no-PIT cohorts

Thom, C., Spirek, B., Mullins, C. and Moak, J., 2026. Quantity matters: Impact of PIT deployment on advanced imaging utilization. The American Journal of Emergency Medicine.


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