Ultrasound availability in the evaluation of ectopic pregnancy in the ED: Comparison of quality and cost-effectiveness with different approaches

The liberal use of ultrasonography has been advocated in patients with firs t trimester cramping or bleeding to avoid misdiagnosis of ectopic pregnancy in the emergency department (ED). The cost-effectiveness of different appr oaches to ultrasound availability has not been previously reported. in this study, we investigated measures of quality and cost-effectiveness in detec ting ectopic pregnancy in the ED over a 6-year period, divided into three a pproximately equal epochs with three distinct approaches to ultrasound avai lability The study retrospectively identified 120 cases of ectopic pregnanc y seen in the ED over 6 years. There was significant improvement in the per centage of patients with ectopic pregnancy who were documented to have abse nce of intrauterine pregnancy (IUP) at the first visit from 76% during Epoc h 1, when there was limited availability of ultrasound through medical imag ing (MI Sono), to 88% in Epoch 2, when MI Sono was readily available, to 96 % in Epoch 3, when both Mi Sono and ultrasound by emergency physicians (ED Sane) were readily available (P = .02). The estimated number of MI Sonos or dered by emergency physicians in patients at risk for ectopic pregnancy inc reased from 5.2 per ectopic pregnancy in Epoch 1 to 11.8 per ectopic pregna ncy in Epoch 2, and declined to 5.5 per ectopic pregnancy in Epoch 3, when 19.9 ED Sonos per ectopic pregnancy were also done. The cost of ED Sono in Epoch 3 was more than offset by savings from avoiding calling in ultrasound technicians after regular medical imaging department hours. The specificit y of ED Sono in ruling in an IUP was 100% (95% Ct 98.3 to 100%), but analys is of secondary quality indicators reflecting times from first ED visit to treatment in Epoch 3 raised the possibility that an adnexal mass or signs o f tubal rupture may have been missed on some ED Sonos. We conclude that inc reased availability of ultrasonography leads to improved quality in the det ection of ectopic pregnancy in the ED, but at the expense of a disproportio nate increase in the number of ultrasound studies done per ectopic pregnanc y detected. Out study suggests that the most cost-effective strategy is for emergency physicians to screen all patients with first trimester cramping and bleeding with ED Sonos, and to obtain MI Sonos at the time of the initi al ED visit in all cases in which the ED Sono is indeterminate or shows no IUP.