Despite longstanding clinical guidance favoring computed tomography for evaluating facial trauma, plain radiography continues to be used as the initial imaging modality in a substantial proportion of cases, according to a large national analysis. The findings suggest persistent gaps between evidence-based recommendations and real-world practice.
In the retrospective cohort study of 281,421 adults with maxillofacial trauma, University of Michigan Medical School researchers found that 26% (72,125 patients) received low-value plain radiography as their initial imaging study, even though computed tomography (CT) is the preferred diagnostic modality because of its higher sensitivity. The study analyzed data from the Merative MarketScan Commercial Claims and Encounters data set from 2013 to 2022.
While the use of plain radiography declined over time — from 33% of cases in 2013 to 18% in 2022 — it remained common across multiple care settings. Concurrently, annual CT use increased during this same period, rising from 67% to 82% of initial imaging studies, reflecting a gradual but still incomplete adoption of guideline-concordant care.
The study also identified several factors associated with the use of low-value imaging. Women had 1.5 times the odds of receiving plain radiography rather than CT compared with men. While the exact drivers for this disparity remain unclear, the researchers suggest that factors such as implicit gender bias in health care and potential underestimation of injury severity in women may contribute to this difference. Practitioner specialty also influenced imaging decisions. Family medicine clinicians were more likely to order radiographs, whereas surgical specialists — including ophthalmologists, otolaryngologists, and plastic surgeons — were substantially less likely to rely on plain films and instead favored CT scans.
The continued use of plain radiography carried measurable downstream consequences. Among patients who initially underwent radiography, 6% required follow-up CT within 7 days. In addition, among radiography-first patients without an initial fracture diagnosis who were later found to have a fracture, 8% had the diagnosis delayed by more than 3 days after the initial imaging study.
Although radiography has lower median direct costs compared with CT, the investigators noted that the true economic burden of low-value imaging may be underestimated, because staff time, institutional overhead, professional interpretation fees, and indirect costs related to missed injuries and diagnostic delays were not included in the data set’s cost estimates.
Taken together, the findings highlight opportunities to improve adherence to imaging guidelines for facial trauma. The researchers suggest that clinical decision support tools, targeted clinician education, and expanded access to CT imaging in urgent care or outpatient settings could help reduce reliance on low-yield radiography and improve diagnostic accuracy, particularly for women and patients in low-acuity settings who may be disproportionately affected. Improving alignment between imaging practices and evidence-based recommendations, they conclude, could help ensure that all patients with maxillofacial trauma receive optimal diagnostics.
The researchers declared having no competing interests.
Source: JAMA Network Open
