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Overutilization of head computed tomography in cases of mild traumatic brain injury: a systematic review and meta-analysis
Abstract
Head computed tomography (CT) is the preferred imaging modality for mild traumatic brain injury (mTBI). The routine use of head CT in low-risk individuals with mild TBI offers no clinical benefit but also causes notable health and financial burden. Despite the availability of related guidelines, studies have reported considerable rate of non-indicated head CT requests. The objectives were to provide an overall estimate for the head CT overutilization rate and to identify the factors contributing to the overuse. A systematic review of PubMed, Scopus, Web of Science, and Embase databases was conducted up to November 2023, following PRISMA and MOOSE guidelines. Two reviewers independently selected eligible articles and extracted data. Quality assessment was performed using a bias risk tool, and a random-effects model was used for data synthesis. Fourteen studies, encompassing 28,612 patients, were included, with 27,809 undergoing head CT scans. Notably, 75% of the included studies exhibited a moderate to high risk of bias. The overutilization rate for pediatric and adult patients was 27% (95% CI: 5–50%) and 32% (95% CI: 21–44%), respectively. An alternative rate, focusing on low-risk pediatric patients, was 54% (95% CI: 20–89%). Overutilization rates showed no significant difference between teaching and non-teaching hospitals. Patients with mTBI from falls or assaults were less likely to receive non-indicated scans. There was no significant association between physician specialty or seniority and overuse, nor between patients’ age or sex and the likelihood of receiving a non-indicated scan. Approximately one-third of head CT scans in mTBI cases are avoidable, underscoring the necessity for quality improvement programs to reduce unnecessary imaging and its associated burdens.
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Background
There is still uncertainty on whether ionizing radiation from CT scans can increase the risks of cancer. This study aimed to identify the association of cumulative ionizing radiation from CT scans with pertaining cancer risks in adults.
Methods
Five databases were searched from their inception to November 15, 2020. Observational studies reporting cancer risks from CT scans in adults were included. The main outcome included quantified cancer risks as cancer case numbers in exposed/unexposed adult participants with unified converted measures to odds ratio (OR) for relative risk, hazard ratio. Global background radiation (2.4 mSv per year) was used as control for lifetime attribution risk (LAR), with the same period from incubation after exposure until survival to 100 years.
Results
25 studies were included with a sum of 111,649,943 participants (mean age: 45.37 years, 83.4% women), comprising 2,049,943 actual participants from 6 studies with an average follow-up period as 30.1 years (range, 5 to 80 years); 109,600,000 participants from 19 studies using LAR. The cancer risks for adults following CT scans were inordinately increased (LAR adults, OR, 10.00 [95% CI, 5.87 to 17.05]; actual adults, OR, 1.17 [95%CI, 0.89 to 1.55]; combined, OR, 5.89 [95%CI, 3.46 to 10.35]). Moreover, cancer risks elevated with increase of radiation dose (OR, 33.31 [95% CI, 21.33 to 52.02]), and multiple CT scan sites (OR, 14.08 [95% CI, 6.60 to 30.05]). The risk of solid malignancy was higher than leukemia. Notably, there were no significant differences for age, gender, country, continent, study quality and studying time phrases.
Conclusions
Based on 111.6 million adult participants from 3 continents (Asia, Europe and America), this meta-analysis identifies an inordinately increase in cancer risks from CT scans for adults. Moreover, the cancer risks were positively correlated with radiation dose and CT sites. The meta-analysis highlights the awareness of potential cancer risks of CT scans as well as more reasonable methodology to quantify cancer risks in terms of life expectancy as 100 years for LAR.
Prospero trial registration number
CRD42019133487.
Background
Inappropriate and wasteful use of health care resources is a common problem, constituting 10–34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging—in which the diagnostic test confers little to no clinical benefit—is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children.
Methods
A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included.
Results
A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations.
Conclusions
A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally.
Systematic review registration : PROSPERO: CRD42020208072.
Computed tomography pulmonary angiography (CTPA) has become the most widely used technique for diagnosis or exclusion of a pulmonary embolism (PE). It has been suggested that overuse of this imaging type may be prevalent, especially in emergency departments (EDs). The purpose of this literature review was to explore the use of CTPAs in EDs worldwide. A review following PRISMA guidelines was completed, with research published between September 2010 and August 2020 included. Five key topics emerged: use of CTPAs; explanations for overuse; use of D-dimer; variability in ordering practices between clinicians; and strategies to reduce overuse. This review found that CTPAs continue to be overused in EDs, leading to superfluous risks to patients. Published studies identify that while clinical practice guidelines (CPGs) have a strong effect on reducing unnecessary CTPAs with no significantly increased risk of missed diagnosis, the adoption of these tools by ED clinicians has remained low. This literature review highlights the need for further research into why CTPAs continue to be overused within EDs and why clinicians are hesitant to use CPGs in the clinical setting. Moreover, investigations into other potential strategies that may combat the overuse of this diagnostic tool are essential to reduce potential harm.
Background
Unnecessary imaging is a potential cost driver in the United States health care system.Objective
Using a clinical decision support tool, we determined the percentage of low-utility non-contrast head computed tomography (CT) examinations on emergency patients and calculated the prospective cost implications of providing low-value imaging using time-driven activity-based costing at an academic quaternary pediatric hospital.Materials and methodsA clinical decision support tool for imaging, CareSelect (National Decision Support Co., Madison, WI), was integrated in silent mode into the electronic health record from September 2018 through August 2019. Each non-contrast head CT order received a score from the clinical decision support tool based on the American College of Radiology Appropriateness Criteria. Descriptive statistics for all levels of appropriateness scores were compiled with an emphasis on low-utility exams. A micro-costing assessment was conducted using time-driven activity-based costing on head CT without contrast examinations.ResultsWithin the 11-month time period, 3,186 head CT examinations without contrast were ordered for emergency center patients. Among these orders, 28% (896/3,186) were classified as low-utility studies. The base case CT pathway time was 43 min and base case total cost was $193.35. The base case opportunity cost of these low-utility exams extrapolated annually amounts to $188,902 for our institution.Conclusion
Silent mode implementation of a clinical decision support tool resulted in 28% of head CT non-contrast exams on emergency patients being graded as low-utility studies. Prospective cost implications resulted in an annual base case cost of $188,902 to Texas Children’s Hospital.
Background
Computed tomography (CT) is used worldwide; however, recent studies suggest that CT radiation exposure during childhood may be a risk factor for cancer, although the data are inconsistent.
Methods
A comprehensive search of electronic databases including PubMed, SpringerLink, Embase, Cochrane Library, Elsevier/ScienceDirect, Medline, Orbis, and Web of Science databases from January 1990 to November 2018 for observational epidemiologic studies reporting associations between radiation exposure from CT in childhood and the subsequent risk of cancer was conducted. A linear model was used to explore the dose–response relationship.
Results
Seven studies with 1180 987 children enrolled were included. The risk of later cancer was 1.32-fold higher for children exposed to CT than those without exposure. Compared to those not exposed to pediatric CT, the relative risk (RRs) were larger for the higher doses but with wider CIs (RR for 5-10 mGy: 0.90, 95% CI: 0.69-1.12; RR for 10-15 mGy: 1.02, 95% CI: 0.86-1.18; RR for >15 mGy: 1.13, 95% CI: 0.97-1.30), the leukemia risk was higher in exposed children (RR: 1.23, 95% CI: 1.10-1.36), and brain cancer risk was higher in exposed children (RR: 1.54, 95% CI: 0.84-2.45).
Conclusions
Our analysis suggested that radiation exposure from CT during childhood is associated with a subsequently elevated risk of cancer. However, caution is needed when interpreting these results because of the heterogeneity among the studies. The findings should be confirmed in further studies with longer follow-up periods.
Objective: To compare the classification accuracy of S100B to two clinical decision rules— Canadian CT Head Rule (CCHR) and New Orleans Criteria (NOC)—for predicting traumatic intracranial injuries (ICI) after mild traumatic brain injury (mild TBI).
Methods: A secondary analysis of a prospective observational study of mild TBI patients was performed. The diagnostic performance of S100B for predicting ICI on head CT was compared to both the CHRR and NOC. Area under receiver operator characteristic (AUC) curves were used and multivariable analysis was used to create a new decision rule based on a combination of S100B and decision rule-related variables.
Results: S100B had the highest negative predictive value (97.3%), positive predictive value (7.21%), specificity (33.6%) and positive likelihood ratio (1.3), and the lowest negative likelihood ratio (0.5). The proportion of mild TBI subjects with potentially avoidable head CT scans was highest using S100B (37.7%). The addition of S100B to both clinical decision rules significantly increased AUC. A novel decision rule adding S100B to three decision rule-related variables significantly improved prediction (p < 0.05).
Conclusion: Serum S100B outperformed clinical decision rules for identifying mild TBI patients with ICI. Incorporating clinical variables with S100B maximized ICI prediction, but requires validation in an independent cohort.
Over 90% of patients with head trauma seen in emergency departments (EDs) are diagnosed with minor head injuries. Over-utilisation of CT scans results in unnecessary exposure to radiation and increases healthcare utilisation. Using recommendations from the Choosing Wisely Canada (CWC) campaign and quality improvement (QI) methodology, we aimed to reduce the CT scan rate for head injuries by 10% over a 6-month period.
Baseline CT scan rates were determined through a 27-month retrospective cohort review. We used stakeholder engagement and provider surveys to develop our driver diagram and Plan-Do-Study-Act (PDSA) cycles, which included (1) improving provider knowledge about the CWC campaign recommendations; (2) testing, refining and implementing a modified Canadian CT Head Rule checklist; (3) developing CWC-themed head injury–specific patient handouts; and (4) feedback on CT scan group ordering rates to providers. Our primary outcome measure was the number of CT scans performed for patients with head injuries. Process measures included the number of checklists completed and ED length of stay (LOS). Our balancing measure was return ED visits within 72 hours (with or without admission).
Baseline CT scan rates prior to our interventions was 46.1%. Our QI initiative resulted in a ‘shift’ in the Statistical Process Control chart of the weekly CT scan rates, associated with the first and second PDSA cycles, resulting in a 13.9% reduction in CT rates during the initial 3 months, and a sustained reduction of 8% at 16 months (p<0.05). Mean ED LOS for all patients with head injuries decreased by 1.5 min (p=0.74). 33% of checklists were completed. 72-hour return visits did not change significantly (p=0.68).
Through provider and patient education, and the creation of a user-friendly evidence-based tool, our local QI initiative was successful in achieving long-term reduction in CT rates for patients presenting to EDs with head injuries.
Objectives
To (1) estimate the proportion of patients seeking care for low back pain (LBP) who are imaged and (2) explore trends in the proportion of patients who received diagnostic imaging over time. We also examined the effect of study-level factors on estimates of imaging proportion.
Data sources
Electronic searches of MEDLINE, Embase and CINAHL databases from January 1995 to December 2017.
Eligibility criteria for selecting studies
Observational designs and controlled trials that reported imaging for patients presenting to primary care or emergency care for LBP. We assessed study quality and calculated pooled proportions by care setting and imaging type, with strength of evidence assessed using the GRADE system.
Results
45 studies were included. They represented 19 451 749 consultations for LBP that had resulted in 4 343 919 imaging requests/events over 21 years. Primary care: moderate quality evidence that simple imaging proportion was 16.3% (95% CI 12.6% to 21.1%) and complex imaging was 9.2% (95% CI 6.2% to 13.5%). For any imaging, the pooled proportion was 24.8% (95% CI 19.3%to 31.1%). Emergency care: moderate quality evidence that simple imaging proportion was 26.1% (95% CI 18.2% to 35.8%) and high-quality evidence that complex imaging proportion was 8.2% (95% CI 4.4% to 15.6%). For any imaging, the pooled proportion was 35.6% (95% CI 29.8% to 41.8%). Complex imaging increased from 7.4% (95% CI 5.7% to 9.6%) for imaging requested in 1995 to 11.4% (95% CI 9.6% to 13.5%) in 2015 (relative increase of 53.5%). Between-study variability in imaging proportions was only partially explained by study-level characteristics; there were insufficient data to comment on some prespecified study-level factors.
Summary/conclusion
One in four patients who presented to primary care with LBP received imaging as did one in three who presented to the emergency department. The rate of complex imaging appears to have increased over 21 years despite guideline advice and education campaigns.
Trial registration number
CRD42016041987.
The number of computed tomography (CT) systems in operation in Japan is approximately 4.3 times higher than that of the OECD average. However, CT systems are expensive, and thus, a heavy financial burden for hospital management. We calculate the annual net profits from CT introduction in Japan for single-slice CT (SSCT), multi-slice CT (MSCT), number of hospital beds, and prefecture. We also analyze the factors that affect CT profitability. First, the annual income per CT in operation is estimated for 2011. Second, the annual costs per CT are calculated as the sum of depreciation, maintenance, and labor costs. Finally, the annual net profits per CT are estimated for SSCT and MSCT, the number of hospital beds, and prefecture. A correlation analysis between the annual net profits, population, and number of physicians per CT equipment is used to determine the determinants of the net CT profits by prefecture. Our results show that, for hospitals with fewer than 100 beds, the annual net CT profits are higher for SSCT than MSCT, and vice versa for hospitals with at least 100 beds. Both SSCT and MSCT increased profits as the number of hospital beds increased. The annual net CT profits per prefecture are USD −12,105 for SSCT and USD 87,233 for MSCT, on average. The annual net profits per prefecture and population per CT show positive correlations with both SSCT and MSCT, as do the annual net profits per prefecture and number of physicians per CT. Thus, choosing high-performance MSCT is advantageous in terms of profitability in facilities with at least 100 beds. Additionally, CT profitability presumably affects the balance between the number of introduced CTs, population per CT, and number of physicians per CT.
Introduction
The Choosing Wisely campaign currently recommends avoiding computed tomography (CT) of the head in low-risk emergency department (ED) patients with minor head injury, based on validated decision rules. However, the degree of adherence to this guideline in clinical practice is unknown. The objective of this study was to evaluate adherence to the Choosing Wisely campaign’s recommendations regarding head CT imaging of patients with minor head injury in the ED.
Methods
We conducted a retrospective cohort study of adult ED patients at a Level I trauma center. Patients aged ≥ 18 years who presented to the ED with minor head injury were identified via International Classification of Diseases, 9th Revision, Clinical Modification codes. Medical record abstraction was conducted to determine the presence of clinical symptoms of the NEXUS II criteria, medical resource use, and head CT findings. We used descriptive statistics to characterize the study sample, and proportions were used to quantify guidelines adherence.
Results
A total of 489 subjects met inclusion criteria. ED providers appropriately applied the Choosing Wisely criteria for 75.5% of patients, obtaining head CTs when indicated by the NEXUS II rule (41.5%), and not obtaining head CTs when the NEXUS II criteria were not met (34.0%). However, ED providers obtained non-indicated CTs in 23.1% of patients. Less than 2% of the sample did not receive a head CT when imaging was indicated by NEXUS II.
Conclusion
ED providers in our sample had variable adherence to the Choosing Wisely head-CT recommendation, especially for patients who did not meet the NEXUS II criteria.
Pediatric urolithiasis is an important and increasingly prevalent cause of pediatric morbidity and hospital admission. Ultrasound (US) is the recommended primary imaging modality for suspected urolithiasis in children. There is, however, widespread use of CT as a first-line study for abdominal pain in many institutions involved in pediatric care. The objective of this review is to outline state-of-the-art imaging modalities and methods for diagnosing urolithiasis in children. The pediatric radiologist plays a key role in ensuring that the appropriate imaging modality is performed in the setting of suspected pediatric urolithiasis. Our proposed imaging algorithm starts with US, and describes the optimal technique and indications for the use of CT. We emphasize the importance of improved communication with a greater collaborative approach between pediatric and general radiology departments so children undergo the appropriate imaging evaluation.
Background
Mild traumatic brain injury (TBI) is associated with substantial costs due to over-triage of patients to computed tomography (CT) scanning, despite validated decision rules. Serum biomarker S100B has shown promise for safely omitting CT scans but the economic impact from clinical use has never been reported. In 2007, S100B was adapted into the existing Scandinavian management guidelines in Halmstad, Sweden, in an attempt to reduce CT scans and save costs. Methods
Consecutive adult patients with mild TBI (GCS 14-15, loss of consciousness and/or amnesia), managed with the aid of S100B, were prospectively included in this study. Patients were followed up after 3 months with a standardized questionnaire. Theoretical and actual cost differences were calculated. ResultsSeven hundred twenty-six patients were included and 29 (4.7 %) showed traumatic abnormalities on CT. No further significant intracranial complications were discovered on follow-up. Two hundred twenty-nine patients (27 %) had normal S100B levels and 497 patients (73 %) showed elevated S100B levels. Over-triage occurred in 73 patients (32 %) and under-triage occurred in 39 patients (7 %). No significant intracranial complications were missed. The introduction of S100B could save 71 € per patient if guidelines were strictly followed. As compliance to the guidelines was not perfect, the actual cost saving was 39 € per patient. Conclusion
Adding S100B to existing guidelines for mild TBI seems to reduce CT usage and costs, especially if guideline compliance could be increased.
Background:
Overuse of computed tomography (CT) for minor head injury continues despite developed and rigorously validated clinical decision rules like the Canadian CT Head Rule (CCHR). Adherence to this sensitive and specific rule could decrease the number of CT scans performed in minor head injury by 35%. But in practice, the CCHR has failed to reduce testing, despite its accurate performance.
Objectives:
The objective was to identify nonclinical, human factors that promote or inhibit the appropriate use of CT in patients presenting to the emergency department (ED) with minor head injury.
Methods:
This was a qualitative study in three phases, each with interview guides developed by a multidisciplinary team. Subjects were recruited from patients treated and released with minor head injuries and providers in an urban academic ED and a satellite community ED. Focus groups of patients (four groups, 22 subjects total) and providers (three groups, 22 subjects total) were conducted until thematic saturation was reached. The findings from the focus groups were triangulated with a cognitive task analysis, including direct observation in the ED (>150 hours), and individual semistructured interviews using the critical decision method with four senior physician subject matter experts. These experts are recognized by their peers for their skill in safely minimizing testing while maintaining patient safety and engagement. Focus groups and interviews were audio recorded and notes were taken by two independent note takers. Notes were entered into ATLAS.ti and analyzed using the constant comparative method of grounded theory, an iterative coding process to determine themes. Data were double-coded and examined for discrepancies to establish consensus.
Results:
Five core domains emerged from the analysis: establishing trust, anxiety (patient and provider), constraints related to ED practice, the influence of others, and patient expectations. Key themes within these domains included patient engagement, provider confidence and experience, ability to identify and manage patient anxiety, time constraints, concussion knowledge gap, influence of health care providers, and patient expectations to get a CT.
Conclusions:
Despite high-quality evidence informing use of CT in minor head injury, multiple factors influence the decision to obtain CT in practice. Identifying and disseminating approaches and designing systems that help clinicians establish trust and manage uncertainty within the ED context could optimize CT use in minor head injury.
Background:
The study aimed to assess the relationship between computed tomography (CT) scan findings and Glasgow Coma Scale (GCS) score with the purpose of introducing GCS scoring system as an acceptable alternative for CT scan to clinically management of brain injuries in head trauma patients.
Materials and methods:
This study was conducted on hospitalized patients with the complaints of head trauma. The severity of the head injury was assessed on admission by the GCS score and categorized as mild, moderate, or severe head injury.
Results:
Of all study subjects, 80.5% had GCS 13-15 that among those, 45% had GCS 15. Furthermore, 10.5% had GCS ranged 9-12 and 9% had GCS <8. Of all subjects, 54.5% had abnormal CT findings that of them, 77.1% categorized as mild head injury, 11.0% had a moderate head injury, and 11.9% had a severe head injury. Furthermore, of those with GCS 15, 41.0% had abnormal CT scan. Of all patients with abnormal CT findings, 33.0% underwent surgery that 61.1% categorized in mild head injury group, 13.9% categorized in moderate head injury group, and 22.2% categorized in severe head injury group. Of those with GCS equal to 15, only 27.0% underwent surgery.
Conclusion:
The use of GCS score for assessing the level of injury may not be sufficient and thus considering CT findings as the gold standard, the combination of this scoring system and other applicable scoring systems may be more applicable to stratify brain injury level.
To determine whether S100B protein in serum can predict intracranial lesions on computed tomography (CT) scan after mild traumatic brain injury (MTBI).
Systematic review and meta-analysis Methods and procedures: A literature search was conducted using Medline, Embase, Cochrane, Google Scholar, CINAHL, SUMSearch, Bandolier, Trip databases, bibliographies from identified articles and review article references. Eligible articles were defined as observational studies including patients with MTBI who underwent post-traumatic head CT scan and assessing the screening role of S100B protein.
There was a significant positive association between S100B protein concentration and positive CT scan (22 studies, SMD = 1.92, 95% CI = 1.29-2.45, I(2) = 100%; p < 0.001). The pooled sensitivity and specificity values for a cut-point range = 0.16-0.20 µg L(-1) were 98.65 (95% CI = 95.53-101.77; I(2) = 0.0%) and 50.69 (95% CI = 40.69-60.69; I(2) = 76.3%), respectively. The threshold for serum S100B protein with 99.63 (95% CI = 96.00-103.25; I(2) = 0.0%) sensitivity and 46.94 (95% CI = 39.01-54.87; I(2) = 95.5%) specificity was > 0.20 µg L(-1).
After MTBI, serum S100B protein levels are significantly associated with the presence of intracranial lesions on CT scan. Measuring the protein could be useful in screening high risk MTBI patients and decreasing unnecessary CT examinations.
Multiple, validated, evidence-based guidelines exist to inform the appropriate use of computed tomography (CT) to differentiate mild traumatic brain injury (MTBI) from clinically important brain injury and to prevent the overuse of CT. Yet, CT use is growing rapidly, potentially exposing patients to unnecessary ionizing radiation risk and costs. A study was conducted to quantify the overuse of CT in MTBI on the basis of current guideline recommendations.
A retrospective analysis of secondary data from a prospective observational study was undertaken at an urban, Level I emergency department (ED) with more than 90,000 visits per year. For adult patients with minor head injury receiving CT imaging at the discretion of the treating physician, the proportion of cases meeting criteria for CT on the basis of the Canadian CT Head Rule (CCHR), American College of Emergency Physicians (ACEP) Clinical Policy, New Orleans Criteria (NOC), and National Institute for Health and Clinical Excellence (NICE) guidelines was reported.
All 346 patients enrolled in the original study were included in the analysis. The proportion of cases meeting criteria for CT for each of the guidelines was: CCHR 64.7% (95% confidence interval [CI], 0.60-0.70), ACEP 74.3% (95% CI, 0.70-0.79), NICE 86.7% (95% CI, 0.83-0.90), and NOC 90.5% (95% CI, 0.87-0.94). The odds ratio of the guidelines for predicting positive head CT findings were also reported.
Some 10%-35% of CTs obtained in the ED for MTBI were not recommended according to the guidelines. Successful implementation of existing guidelines could decrease CT use in MTBI by up to 35%, leading to a significant reduction in radiation-induced cancers and health care costs.
ii This report is based on research conducted by the RTI International–University of North Carolina Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10056-I). The findings and conclusions in this document are those of the author(s), who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.
Computed tomography (CT) is widely used as a screening test in patients with minor head injury, although the results are often normal. We performed a study to develop and validate a set of clinical criteria that could be used to identify patients with minor head injury who do not need to undergo CT.
In the first phase of the study, we recorded clinical findings in 520 consecutive patients with minor head injury who had a normal score on the Glasgow Coma Scale and normal findings on a brief neurologic examination; the patients then underwent CT. Using recursive partitioning, we derived a set of criteria to identify all patients who had abnormalities on CT scanning. In the second phase, the sensitivity and specificity of the criteria for predicting a positive scan were evaluated in a group of 909 patients.
Of the 520 patients in the first phase, 36 (6.9 percent) had positive scans. All patients with positive CT scans had one or more of seven findings: headache, vomiting, an age over 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicles, and seizure. Among the 909 patients in the second phase, 57 (6.3 percent) had positive scans. In this group of patients, the sensitivity of the seven findings combined was 100 percent (95 percent confidence interval, 95 to 100 percent). All patients with positive CT scans had at least one of the findings.
For the evaluation of patients with minor head injury, the use of CT can be safely limited to those who have certain clinical findings.
Minor head injury is the most common type of head injury. Despite of high incidence and numerous studies performed, there is much controversy about correct evaluation of these patients. The aim of this study was to find clinical signs and symptoms which help to predict the indications for brain CT scan following minor head injury.
A series of 682 consecutive patients who had been attended at two university hospitals (Alzahra and Kashani) with minor head injury (GCS=15) were prospectively enrolled in this cohort study. In all cases clinical signs and symptoms were collected and a cranial computerized tomography (CT) scan was obtained. The relationship between the occurrence of clinical findings and appearance of intracranial posttraumatic lesions on cranial CT was analyzed by chi-square tests and statistic logistic regression methods, with 95% confidence intervals.
Of 682 patients, 46 (6.7%) presented brain injuries on CT scan. All patients with abnormal CT scans had at least one of the following factors (risk factors): posttraumatic amnesia, loss of consciousness, posttraumatic seizure, headache, vomiting, focal neurological deficit, skull fracture, coagulopathy or antecedent of treatment with anticoagulants and patient age older than 60 years. No abnormal CT scans were found among patients without any of those risk factors on admission. Vomiting, skull fracture and age greater than 60 years were risk factors significantly correlated to an abnormal cranial CT after head injury. The presence of several risk factors in a patient increased the probability of posttraumatic lesion on CT scan.
Some clinical risk factors can be used as a guide to predict the probability of abnormal CT following minor head injury.
Study objective
Unnecessary computed tomography (CT) scans burden the health care system, leading to increased emergency department (ED) wait times and lengths of stay, costing almost a billion dollars annually. This study aimed to describe ED-based interventions that are most effective at reducing CT imaging while maintaining diagnostic accuracy and patient safety.
Methods
Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and Google Scholar were searched until December 31, 2020. Randomized and nonrandomized studies that assessed the effect of an ED-based intervention on CT scan usage were included. Abstract screening, data extraction, and quality assessment were conducted in duplicate. The Grading of Recommendation Assessment, Development and Evaluation framework, with the Risk of Bias 2 and Risk of Bias in Nonrandomized Studies - of Interventions tools, was used to determine the certainty of evidence. Significant clinical and statistical heterogeneity precluded meta-analysis; hence, a narrative synthesis was conducted.
Results
A total of 149 studies were included of 5,667 screened abstracts, with substantial interrater reliability among reviewers (Cohen’s κ>0.60). The CT reduction strategies were categorized into 15 single and 11 multimodal interventions by consensus review. Interventions that consistently reduced CT usage included diagnostic pathways, alternative test availability, specialist involvement, and provider feedback. Family/patient education, clinical decision support tools, or passive guideline dissemination did not consistently reduce usage. Only 44% of studies reported unintended consequences of reduction strategies; however, these showed no increase in missed diagnoses or patient harm. The interventions that engaged multiple specialties during planning/implementation had a greater reduction effect than ED only. The certainty of evidence for the primary outcome was very low.
Conclusion
Multidisciplinary-led interventions that provided an alternative to CT imaging were the most effective at reducing usage and did so without compromising patient safety.
Background One of the best practices for timely and efficient diagnoses of central nervous system (CNS) trauma and complex diseases is imaging. However, rates of imaging for CNS are high and impose a lot of costs to health care facilities in addition to exposing patients with negative impact of ionizing radiation.
Objectives This study aimed to systematically review the effects and features of clinical decision support systems (CDSSs) for the appropriate use of imaging for CNS injuries.
Method We searched MEDLINE, SCOPUS, Web of Science, and Cochrane without time period restriction. We included experimental and quasiexperimental studies that assessed the effectiveness of CDSSs designed for the appropriate use of imaging for CNS injuries in any clinical setting, including primary, emergency, and specialist care. The outcomes were categorized based on imaging-related, physician-related, and patient-related groups.
Result A total of 3,223 records were identified through the online literature search. Of the 55 potential papers for the full-text review, 11 eligible studies were included. Reduction of CNS imaging proportion varied from 2.6 to 40% among the included studies. Physician-related outcomes, including guideline adherence, diagnostic yield, and knowledge, were reported in five studies, and all demonstrated positive impact of CDSSs. Four studies had addressed patient-related outcomes, including missed or delayed diagnosis, as well as length of stay. These studies reported a very low rate of missed diagnosis due to the cancellation of computed tomography (CT) examine according to the CDSS recommendations.
Conclusion This systematic review reports that CDSSs decrease the utilization of CNS CT scan, while increasing physicians' adherence to the rules. However, the possible harm of CDSSs to patients was not well addressed by the included studies and needs additional investigation. The actual effect of CDSSs on appropriate imaging would be realized when the saved cost of examinations is compared with the cost of missed diagnosis.
Objectives
Low-value clinical practices have been identified as one of the most important areas of excess healthcare spending. Nevertheless, there is a knowledge gap on the scale of this problem in injury care. We aimed to identify clinical practice guideline (CPG) recommendations pertaining to low-value injury care, estimate how frequently they are used in practice, and evaluate interhospital variations in their use.
Methods
We identified low-value clinical practices from internationally recognized CPGs. We conducted a retrospective cohort study using data from a Canadian trauma system (2014-2019) to calculate frequencies and assess interhospital variations.
Results
We identified 29 low-value practices. Fourteen could be measured using trauma registry data. The 3 low-value clinical practices with the highest absolute and relative frequencies were computed tomography (CT) in adults with minor head injury (n = 5591, 24%), cervical spine CT (n = 2742, 31%), and whole-body CT in minor or single-system trauma (n = 530, 32%). We observed high interhospital variation for decompressive craniectomy in diffuse traumatic brain injury. Frequencies and interhospital variations were low for magnetic resonance imaging, intracranial pressure monitoring, inferior vena cava filter use, and surgical management of blunt abdominal injuries.
Conclusions
We observed evidence of poor adherence to CPG recommendations on low-value CT imaging and high practice variation for decompressive craniectomy. Results suggest that adherence to recommendations for the 10 other low-value practices is high. These data can be used to advance the research agenda on low-value injury care and inform the development of interventions targeting reductions in healthcare overuse in this population.
A computed tomographic (CT) scan of the head is commonly used in the emergency department for patients who present with minor head injury. Frequent use of CT imaging contributes to health care costs, radiation exposure, and emergency department length of stay. The objective of this project was to decrease unnecessary head CT scans for patients presenting with minor head injury. A clinical decision pathway using the Canadian CT Head Rule was implemented. There was a 12% decrease in head CT use over 8 weeks, and no brain injuries were missed. These outcomes support the implementation of a clinical pathway using the Canadian CT Head Rule on a larger scale.
Introduction
CT scan is crucial in evaluating head trauma. However, its inappropriate use will cause unnecessary radiation exposure to patient and financial burden to health systems. Our aim is appraising amount of brain CT scans performed in our Emergency Department (ED) for evaluating mild head trauma which are not indicated according to four standardized guidelines as well as analyzing contributing factors.
Methods
This was a descriptive prospective study. We included randomly selected adult patients under 75 years old with minor head trauma evaluated by brain CT scan at our ED. For all patients, we completed a checklist including demographic data, mechanism of trauma, specialty of the requesting physician, and whether the patient meets the brain CT guidelines criteria. Brain CT overuse was defined as scans performed for patients without criteria of any of the standardized guidelines.
Results
We evaluated 170 patients. The mean age of patients was 38.38 ± 19.73 years old. The most common mechanism of trauma was falling (37.6%). The overall brain CT scan overuse was 15.3%. Most of the overused scans were performed in younger patients, and patient’s age was inversely correlated to overuse. There was no significant difference based on the mechanism of trauma and the specialty of requesting physician.
Discussion
Our study accentuates the high frequency of brain CT scan overuse, leading to unnecessary radiation exposure and financial burden on healthcare systems. We emphasize that using a guideline for requesting brain CT scan can eliminate unnecessary scans along with detecting patients with important decisive damages.
Background
Prompt diagnosis and treatment of paediatric urolithiasis are required to avoid long term sequelae of renal damage.
Objective
To systematically review the literature regarding the diagnostic imaging modalities and treatment approaches for paediatric urolithiasis.
Study design
PubMed, Science Direct, Scopus and Web of Science were systematically searched from January 1980- January 2019. 76 full-text articles were included.
Results
Ultrasound and Kidney-Ureter-Bladder radiography are the baseline diagnostic examinations. Non-contrast Computed Tomography (CT) is the second line choice with high sensitivity (97-100%) and specificity (96-100%). Magnetic Resonance Urography accounts only for 2% of pediatric stone imaging studies. Expectant management for single, asymptomatic lower pole renal stones is an acceptable initial approach, especially in patients with non-struvite, non-cystine stones<7 mm. Limited studies exist on medical expulsive therapy as off-label treatment. Extracorporeal shock wave lithotripsy (SWL) is the first-line treatment with overall stone free rates (SFRs) of 70-90%, retreatment rates 4-50% and complication rates up to 15%. Semi-rigid ureteroscopy is effective with SFRs of 81-98%, re-treatment rates of 6.3-10% and complication rates of 1.9-23%. Flexible ureteroscopy has shown SFRs of 76-100%, retreatment rates of 0-19% and complication rates of 0-28%. SFRs after first and second-look percutaneous nephrolithotomy (PNL) are 70.1-97.3% and 84.6-97.5%, respectively with an overall complication rate of 20%. Open surgery is seldom used, while laparoscopy is effective for stones refractory to SWL and PNL. Limited data exist for robot-assisted management.
Conclusions
In the initial assessment of paediatric urolithiasis, US is recommended as first imaging modality, while non-contrast CT is the second option. SWL is recommended as first line treatment for renal stones <20 mm and for ureteral stones<10 mm. Ureteroscopy is a feasible alternative both for ureteral stones not amenable to SWL as well as for renal stones <20 mm (using flexible). PNL is recommended for renal stones >20 mm.
Introduction: Choosing Wisely Nova Scotia (CWNS), an affiliate of Choosing Wisely Canada™ (CWC), aims to address unnecessary care and testing through literature-informed lists developed by various disciplines. CWC has identified unnecessary head CTs among the top five interventions to question in the Emergency Department (ED). Zyluk (2015) determined the Canadian CT Head Rule (CCHR) as the most effective clinical decision rule in adults with minor head injuries. To better understand the current status of CCHR use in Nova Scotia, we conducted a retrospective audit of patient charts at the Charles V. Keating Emergency and Trauma Center, in Halifax, Nova Scotia. Methods: Our mixed methods design included a literature review, retrospective chart audit, and a qualitative audit-feedback component with participating physicians. The chart audit applied the guidelines for adherence to the CCHR and reported on the level of compliance within the ED. Analysis of qualitative data is included here, in parallel with in-depth to contextualize findings from the audit. Results: 302 charts of patients having presented to the surveyed site were retrospectively reviewed. Of the 37 cases where a CT head was indicated as per the CCHR, a CT was ordered 32 (86.5%) times. Of the 176 cases where a CT head was not indicated, a CT was not ordered 155 (88.1%) times. Therefore, the CCHR was followed in 187 (87.8%) of the total 213 cases where the CCHR should be applied. Conclusion: Our study reveals adherence to the CCHR in 87.8% of cases at this ED. Identifying contextual factors that facilitate or hinder the application of CCHR in practice is critical for reducing unnecessary CTs. This work has been presented to the physician group to gain physician engagement and to elucidate enablers and barriers to guideline adherence. In light of the frequency of CT heads ordered EDs, even a small reduction would be impactful.
Background:
One of the most common complaints about presentation at the Emergency Department (ED) in childhood is minor head trauma. In recent years, clinical decision rules (CDRs) have been published to assist in determining the need for performing computed tomography (CT) in these patients. The present study aims to investigate the compliance with Pediatric Emergency Care Applied Research Network (PECARN) rules in the decisions for CT examination in children aged below two years old with minor head trauma in our center.
Methods:
This retrospective, single-center study was conducted on a patient group aged below two years old, who presented at the ED within 24 hours of a trauma incident and were diagnosed as mild head trauma Glasgow Coma Scale score 14 and 15).
Results:
A total of 262 patients were included in this study. Of these patients, 214 (81.7%) received CT examination, and 48 (18.3%) patients did not receive any CT examination. None of these 48 patients showed clinically important traumatic brain injury (ci TBI). Among 214 patients who received CT examination, 89 (34%) patients met the PECARN rules criteria and 125 (47.7%) patients did not meet PECARN rules criteria. None of the patients who received CT examination and did not meet the PECARN rules criteria showed ci TBI. Among 89 patients who recieved a CT examination and also met the PECARN rules criteria, only 4 (1.5%) patients showed ci TBI. According to these results, the rate of compliance with PECARN rules in our institution ED was 52.3%.
Conclusion:
In this study, which was conducted by including all the predictor values of the PECARN guidelines, the rate of compliance with PECARN rules was determined to be very low. Using these rules directly or with modification could establish a starting point for clinicians to reduce the rates of unnecessary CT scans. However, the effects of the clinician's experience, parental expectations, medicolegal constraints and economic factors on the decision making process should not be forgotten.
Pulmonary embolism (PE) is an increasingly recognised condition which is associated with significant morbidity and mortality. Despite the better awareness of this serious condition, the diagnosis is still overlooked in many cases with sometimes fatal consequences. Under-diagnosis may be due to several reasons including reliance on non-specific ‘classic’ symptoms, belief that bedside measurements will likely be abnormal in the setting of acute PE, and confounding factors like co-existent cardiorespiratory diseases or being in an intensive care unit, where the diagnosis may not be considered. At the same time, incidental diagnosis of PE is occurring more often due to frequent use of imaging investigations alongside advancements in CT technology, and dilemma exists as to whether the chance finding of PE requires anticoagulation, especially when identified only at the subsegmental level. This article reviews these two issues of under-diagnosis and over-diagnosis of PE in the current era.
Background
The validated Pediatric Emergency Care Applied Network (PECARN) rule helps determine the relevance of a head computerized tomography (CT) for children with mild traumatic brain injury (mTBI). We sought to estimate the potential overuse of head CT within two Canadian emergency departments (EDs).
Methods
We conducted a retrospective chart review of children seen in 2016 in a paediatric Level I (site 1) and a general Level II (site 2) trauma centre. We reviewed charts to determine the appropriateness of head CT use according to the PECARN rule in a random subset of children presenting with head trauma. Simple descriptive statistics were applied.
Results
One thousand five hundred and forty-six eligible patients younger than 17 years consulted during the study period. Of the 203 randomly selected cases per setting, 16 (7.9%) and 24 (12%), respectively from sites 1 and 2 had a head CT performed. Based on the PECARN rule, we estimated the overuse for the younger group (<2 years) to be below 3% for both hospitals without significant difference between them. For the older group (≥2 years), the overuse rate was higher at site 2 (9.3%, 95% confidence interval [CI]: 4.8 to 17% versus 1.2%, 95% CI: 0.2 to 6.5%, P=0.03).
Conclusion
Both EDs demonstrated overuse rates below 10% although it was higher for the older group at site 2. Such low rates can potentially be explained by the university affiliation of both hospitals and by two Canadian organizations working to raise awareness among physicians about the overuse of diagnostic tools and dangers inherent to radiation.
Background
Degree of compliance with Pediatric Emergency Care Applied Research Network (PECARN) recommendations for radiographic evaluation following minor head injury in children is not well understood. The aim of this study was to assess PECARN compliance at a pediatric trauma center. The secondary aim was to determine whether children with indeterminate history of loss of consciousness (LOC) are at greater risk for clinically important traumatic brain injury (ciTBI) than those with no LOC.
Materials and methods
We identified children aged 0-17 y who presented <24 h after minor head injury with Glasgow Coma Scale ≥14 in our institutional trauma registry. Predictor variables for ciTBI (TBI resulting in admission ≥2 nights, intubation ≥24 h, neurosurgery, or death) were reviewed. Simple and multivariate logistic regressions were performed to estimate the independent effects of demographic and clinical characteristics on the outcome of ciTBI.
Results
We included 739 children. Incidence of ciTBI was 5.4%. Only 5.6% did not undergo computed tomography (CT). PECARN compliance was 92.6% overall, but only 23.0% in those for whom CT was not indicated. Among those for whom either CT or observation was acceptable, 93.7% underwent CT. LOC history was indeterminate in 8.5%. On multivariate analysis, indeterminate LOC was not a risk factor for ciTBI. Vomiting and presence of occipital/parietal/temporal scalp hematoma were independent risk factors for ciTBI.
Conclusions
CT is overutilized in pediatric trauma patients presenting to our institution after minor head injury when compared to PECARN criteria. Indeterminate LOC history was not a risk factor for ciTBI. Education of parents and clinicians regarding the risk to benefit ratio of CT in trauma patients with minor head injury is needed.
Purpose
To evaluate whether the emergency department usage of head computed tomography (CT) on pediatric patients with minor head trauma changed after publication of the Pediatric Emergency Care Applied Research Network (PECARN) head CT guidelines and to identify risk factors associated with performing head CT on patients without a PECARN guideline indication.
Methods
This retrospective study included 484 patients 18 years of age or younger who presented to the emergency department with head injury and a total Glasgow Coma Scale score ≥ 14 between September 2005 and July 2014. Based on the guideline publication date of September 2009, the study cohort was stratified into pre-guideline and post-guideline groups. Head CT performance, indications, and findings were compared between study periods. Logistic regression was used to identify risk factors associated with performing a non-indicated head CT.
Results
The rate of head CTs performed did not significantly change in the post-guideline period (96.6% vs. 95.7%, p = 0.63). There was no significant difference in the proportion of head CTs performed in patients with indications for head CT (100.0% vs. 100.0%) nor in patients without an indication for head CT (85.7% vs. 82.6%, p = 0.65) between the study periods. Females were significantly more likely to have a non-indicated head CT (OR: 2.73, 95% CI: 1.67–4.45) performed.
Conclusions
Head CT ordering practices for pediatric patients with head injury did not change at a level I trauma center after publication of the PECARN head CT guidelines.
Introduction:
The American College of Emergency Physicians embarked on the "Choosing Wisely" campaign to avoid computed tomographic (CT) scans in patients with minor head injury who are at low risk based on validated decision rules. We hypothesized that a Pediatric Mild Head Injury Care Path could be developed and implemented to reduce inappropriate CT utilization with support of a clinical decision support tool (CDST) and a structured parent discussion tool.
Methods:
A quality improvement project was initiated for 9 weeks to reduce inappropriate CT utilization through 5 interventions: (1) engagement of leadership, (2) provider education, (3) incorporation of a parent discussion tool to guide discussion during the emergency department (ED) visit between the parent and the provider, (4) CDST embedded in the electronic medical record, and (5) importation of data into the note to drive compliance. Patients prospectively were enrolled when providers at a pediatric and a freestanding ED entered data into the CDST for decision making. Rate of care path utilization and head CT reduction was determined for all patients with minor head injury based on International Classification of Diseases, Ninth Revision codes. Targets for care path utilization and head CT reduction were established a priori. Results were compared with baseline data collected from 2013.
Results:
The CDST was used in 176 (77.5%) of 227 eligible patients. Twelve patients were excluded based on a priori criteria. Adherence to recommendations occurred in 162 (99%) of 164 patients. Head CT utilization was reduced from 62.7% to 22% (odds ratio, 0.17; 95% confidence interval, 0.12-0.24) where CDST was used by the provider. There were no missed traumatic brain injuries in our study group.
Conclusion:
A Pediatric Mild Head Injury Care Path can be implemented in a pediatric and freestanding ED, resulting in reduced head CT utilization and high levels of adherence to CDST recommendations.
Background context:
The problem of imaging patients with low back pain (LBP) when it is not indicated is well recognised. The converse is also possible, although rarely considered. The extent of these two problems is presently unclear.
Purpose:
To estimate how commonly overuse, and also underuse, of imaging occurs in the management of LBP, and how appropriate use of imaging is assessed.
Design:
Systematic review and meta-analysis PATIENT SAMPLE: Patients with low back pain presenting to primary care.
Outcome measures:
Proportions of inappropriate referral, and inappropriate non-referral, for diagnostic imaging for low back pain.
Methods:
MEDLINE, EMBASE, and CINAHL were searched from 1st January 1995 to 17th December 2017. Two authors independently assessed study quality and extracted data. Meta-analyses were performed where appropriate, and strength of evidence was assessed using the GRADE system.
Results:
Thirty-three studies were included. In patients referred for lumbar imaging, 34.8% (95%CI: 27.1, 43.3) were judged inappropriate by the absence of red flags for serious pathology and 31.6% (95%CI: 28.3, 35.1) were judged inappropriate by the criteria of no clinical suspicion of pathology. In patients presenting for care, imaging was inappropriately performed in 27.7% of cases (95%CI: 21.3, 35.1) when judged by duration of episode, 9.0% of cases (95%CI: 7.4, 11.0) when judged by absence of red flags and 7.0% (95%CI: 1.8, 23.3) when judged by no clinical suspicion of pathology. In patients presenting for care, imaging was not performed where appropriately indicated in 65.6% (95%CI: 51.8, 77.2) of patients who presented with red flags, and 60.8% (95%CI: 42.0, 76.8) with clinical suspicion of serious pathology.
Conclusions:
Inappropriate imaging is common in LBP management, including both overuse in those where imaging is not indicated and underuse of imaging when it is indicated. Appreciating that both underuse and overuse can occur is fundamental to efforts to improve imaging practice to align with current guidelines and best evidence.
Aim:
To assess the amount of computed tomography (CT) scans for minor head injury (MHI) performed in young patients in our emergency department (ED), not indicated by National Institute for Health and Clinical Excellence (NICE) and Canadian Computed Tomography Head Rules (CCHR), and to analyze factors contributing to unnecessary examinations. Secondary objectives were to calculate the effective dose, to establish the number of positive CT and to analyze which of the risk factors are correlated with positivity at CT; finally, to calculate sensitivity and specificity of NICE and CCHR in our population.
Materials and methods:
We retrospectively evaluated 493 CT scans of patients aged 18-45 years, collecting the following parameters from ED medical records: patient demographics, risk factors indicating the need of brain imaging, trauma mechanism, specialty and seniority of the referring physician. For each CT, the effective dose and the negativity/positivity were assessed.
Results:
357/493 (72%) and 347/493 (70%) examinations were not in line with the CCHR and NICE guidelines, respectively. No statistically significant difference between physician specialty (p = 0.29 for CCHR; p = 0.24 for NICE), nor between physician seniority and the amount of inappropriate examinations (p = 0.93 for CCHR, p = 0.97 for NICE) was found but CT scans requested by ED physicians were less inappropriate [p = 0.28, odds ratio (OR) 0.562, CI (95%) 0.336-0.939]. There was no statistically significant correlation between patient age and over-referral (p = 0.74 for NICE, p = 0.93 for CCHR). According to NICE, low speed motor vehicle accident (p = 0.009), motor vehicle accident with high energy impact (p < 0.01) and domestic injuries (p = 0.002) were associated with a higher rate of unwarranted CT; according to CCHR only motor vehicle accident with high energy impact showed a significant correlation with unwarranted CT scan (p < 0.001, OR 44.650, CI 33.123-1469.854). 2% of CT was positive. Multivariate analysis demonstrated that factors significantly associated with CT scan positivity included signs of suspected skull fracture (p < 0.001, OR 20.430, CI 2.727-153.052) and motor vehicle accident with high energy impact (p < 0.001, OR 220.650, CI 33.123-1469.854). In our series, CCHR showed sensitivity of 100%, specificity of 74%; NICE showed sensitivity of 100%, specificity of 72%.
Conclusion:
We observed an important overuse of head CT scans in MHI; the main promoting factor for inappropriate was injury mechanism. 2% of head CT were positive, correlating with signs of suspected skull fracture and motor vehicle accident with high energy impact.
Objective:
To adumbrate differences in neurosurgical intervention (NI) rates between intracranial hemorrhage (ICH) types in mild traumatic brain injuries (mTBIs), and help identify which ICH types are most likely to benefit from the creation of predictive models for NI.
Methods:
This was a multi-center retrospective study of adult patients over three years at four Trauma Centers in the USA. Patients were included if they presented with a mTBI (GCS 13-15) and a head CT positive for ICH. Patients were excluded for skull fractures, "unspecified hemorrhage", or coagulopathy. The primary outcome was NI. Stepwise multivariable logistic regression models were built to analyze the independent association between ICH variables and outcome measures.
Results:
1,876 patients were included in our study. The NI rate was 6.7%. There was a significant difference in the rate of NI by ICH type. Subdural hematomas carried the highest rate of NI (15.5%), and accounted for 78% of all NIs. Isolated SAHs carried the lowest, non-zero, NI rate (0.19%). Logistic regression models identified ICH type as the most influential independent variable when examining NI. A model predicting NI for isolated SAHs would require 26,928 patients, but a model predicting NI for isolated SDHs would only require 328 patients.
Conclusion:
Our study highlights the disparate NI rates among ICH types in the mTBI population, and identified mild, isolated SDHs as most appropriate for the construction of predictive NI models. Increased healthcare efficiency will be driven by an accurate understanding of risk, which can only come from accurate predictive models.
Study objective:
Approximately 1 in 3 computed tomography (CT) scans performed for head injury may be avoidable. We evaluate the association of implementation of the Canadian CT Head Rule on head CT imaging in community emergency departments (EDs).
Methods:
We conducted an interrupted time-series analysis of encounters from January 2014 to December 2015 in 13 Southern California EDs. Adult health plan members with a trauma diagnosis and Glasgow Coma Scale score at ED triage were included. A multicomponent intervention included clinical leadership endorsement, physician education, and integrated clinical decision support. The primary outcome was the proportion of patients receiving a head CT. The unit of analysis was ED encounter, and we compared CT use pre- and postintervention with generalized estimating equations segmented logistic regression, with physician as a clustering variable. Secondary analysis described the yield of identified head injuries pre- and postintervention.
Results:
Included were 44,947 encounters (28,751 preintervention and 16,196 postintervention), resulting in 14,633 (32.6%) head CTs (9,758 preintervention and 4,875 postintervention), with an absolute 5.3% (95% confidence interval [CI] 2.5% to 8.1%) reduction in CT use postintervention. Adjusted pre-post comparison showed a trend in decreasing odds of imaging (odds ratio 0.98; 95% CI 0.96 to 0.99). All but one ED reduced CTs postintervention (0.3% to 8.7%, one ED 0.3% increase), but no interaction between the intervention and study site over time existed (P=.34). After the intervention, diagnostic yield of CT-identified intracranial injuries increased by 2.3% (95% CI 1.5% to 3.1%).
Conclusion:
A multicomponent implementation of the Canadian CT Head Rule was associated with a modest reduction in CT use and an increased diagnostic yield of head CTs for adult trauma encounters in community EDs.
Purpose:
The aim of this study was to estimate the amount of CT studies performed in the emergency department of a tertiary hospital that are not indicated by Canadian CT Head Rule (CCHR) guidelines and to analyze factors that contribute to unnecessary examinations.
Methods:
A total of 955 brain CT examinations performed for minor head injuries were randomly retrospectively selected. Medical records were assessed for the following parameters: demographics, cause of head trauma, and referring physician's seniority and specialty. For each CT scan, it was determined whether the CT referral met the CCHR criteria. The CT interpretations of patients under 65 years of age were evaluated to assess the sensitivity and negative predictive value of the CCHR criteria.
Results:
A total of 104 examinations (10.9%) were not indicated according to the CCHR, but in patients younger than 65 years, 104 of 279 examinations (37.3%) were not indicated. Neurologists conducted more unwarranted CT studies (odds ratio [OR], 3.5; P = .011), whereas surgeons tended to order fewer studies (OR, 0.676; P = .126). There was no statistically significant difference between the seniority of the referring physician and over-referral (P = .181). Four-wheel motor vehicle accidents (OR, 2.789; P = .001) and a hit on the head by an object (OR, 2.843; P = .006) were associated with a higher rate of nonindicated CT examinations. The CCHR had sensitivity and negative predictive value of 100% for either brain hemorrhage or fractures.
Conclusions:
Overuse of CT examinations for minor head injuries was demonstrated, especially in young patients, with an excess of 37.3%. Contributing factors are referring physician specialty and injury mechanism. Analysis of overuse causes can be implemented for education programs and for computerized referring protocols.
Purpose
With the overall rise in the use of medical imaging over the past two decades, overutilization has become a major concern. The ACR Appropriateness Criteria (AC) are an evidence-based, web-based, peer-reviewed resource designed to assist clinicians in making the most appropriate imaging decisions. In this literature review, the authors assess the current knowledge, utilization, and education of the AC among undergraduate and graduate medical education trainees and practicing physicians in both radiologic and nonradiologic specialties.
Methods
A comprehensive literature search was completed using the PubMed, Cochrane, and MedEdPORTAL databases with the query “American College of Radiology Appropriateness Criteria.” Articles written in English and published from 1993, the year when the AC were introduced, to present were included for review. Retrieved articles were reviewed for relevance.
Results
The published literature is sparse. A review suggests a low rate of incorporation of the AC into clinical practice. Formal training in appropriate imaging ordering practices in both undergraduate and graduate medical education is lacking. The several studies targeting the use of the AC demonstrate that educational interventions increase awareness of the criteria as a decision tool.
Conclusions
The low rate of incorporation of the AC into clinical practice may reflect the lack of formal training in appropriate imaging order practices, specifically in the use of the AC, in both undergraduate and graduate medical education. The integration of the AC into decision support may reduce overutilization, but this has not been fully studied. Greater integration of the AC into medical training would require more universal physician buy-in to use the AC as a resource to optimize imaging utilization. This further requires sustained efforts to improve the “user-friendliness” of the AC and maximization of collaboration with nonradiology specialties in the development of the AC.
Very few children and young people who present with head injury will have significant intracranial pathology. This presents a common diagnostic dilemma for physicians, as these injuries need to be rapidly identified.1 The previous National Institute of Health and Care Excellence (NICE) head injury guidelines published in 2003 and updated in 2007, established CT scan as the primary imaging modality in head injury. CT provides rapid, definite diagnosis of intracranial injuries, and guides subsequent neurosurgical management, but is associated with significant risks and costs.2 ,3 This NICE update is necessary to ensure the best evidence-based practice regarding initial assessment of head injury and ensuring rapid imaging where appropriate. This NICE guideline also updates some terminology regarding safeguarding children, as the injuries of up to 30% of children aged under 2 years admitted with head injury will be the result of non-accidental/abusive injury.4 As well as reviewing indications and timing of CT brain in the emergency department (ED), this update also addresses indications for transporting head-injured patients directly from the scene to the nearest neuroscience centre, and information that should be given on discharge of head-injured patients. Although this guideline includes adults, for the purposes of review, this paper will focus on children and young people.
The Canadian CT Head Rule attempts to standardize the practice of obtaining head computed tomography (CT) scans in patients with minor head injury. Previous research indicates 10 to 35 per cent of CT scans performed do not meet these guidelines. The purpose of this study was to review our use of CT scans in the evaluation of mild traumatic brain injury and to identify 1) unnecessary head CT scans (UHCT); 2) variables associated with UHCT; and 3) associated costs. Using a trauma registry, inclusion criteria were age older than 18 years, Glasgow Coma Scale of 15, and at least one head CT scan. UHCTs were those without head injury, loss of consciousness, amnesia, or neurologic complaint. The proportion of patients meeting the criteria for UHCT was 24.2 per cent. Univariate analyses revealed ages 41 to 64 years, drug use, vehicular injury, and surgery within 24 hours were associated with UHCT (all P < 0.05). UHCTs were associated with higher Injury Severity Scores (P = 0.008), ventilator days, and length of stay (all P < 0.05). An average cost of $1,413 per CT equals $149,778 in extra costs. This study suggests that current practices at our Level I trauma center result in UHCT. Further investigation into best practices would benefit our center by reducing costs and providing quality patient care.
Head injury causes significant morbidity and mortality, and there is contention about which patients to scan. The UK National Health Service Clinical Guideline (CG) 56 provides criteria for selecting patients with clinically important brain injury who may benefit from a head CT scan, while minimising the radiation and economic burden of scanning patients without significant injury. This study aims to audit the documentation of the use of these guidelines in a busy UK trauma hospital and discusses the comparison with an Australian (New South Wales (NSW) ) head injury guideline.
A retrospective cohort study of 480 patients presenting with head injury to the emergency department over 2 months was performed. The patient notes were assessed for documentation of each aspect of the clinical guidelines. Criteria were established to assess the utilisation of the CG 56. A database of clinical data was amalgamated with the head CT scan results for each patient.
For the UK CG 56, 73% of the criteria were documented, with the least documented being 'signs of basal skull fracture' and 'amnesia of events'. Thirty-two per cent of patients received head CT and of these, 24% (37 patients) were reported to have pathology. Twenty-four patients underwent head CT without clinical justification being documented, none of which had reported pathology on CT.
The study shows that the head injury guidelines are not being fully utilised at a major UK trauma hospital, resulting in 5% of patients being exposed to ionising radiation without apparent documented clinical justification. The NSW guideline has distinct differences to the CG 56, with a more complex algorithm and an absence of specific time frames for head CT completion. The results suggest a need for further education and awareness of head injury clinical guidelines.
In the course of performing systematic reviews on the prevalence of low back and neck pain, we required a tool to assess the risk of study bias. Our objectives were to (1) modify an existing checklist and (2) test the final tool for interrater agreement.
The final tool consists of 10 items addressing four domains of bias plus a summary risk of bias assessment. Two researchers tested the interrater agreement of the tool by independently assessing 54 randomly selected studies. Interrater agreement overall and for each individual item was assessed using the proportion of agreement and Kappa statistic.
Raters found the tool easy to use, and there was high interrater agreement: overall agreement was 91% and the Kappa statistic was 0.82 (95% confidence interval: 0.76, 0.86). Agreement was almost perfect for the individual items on the tool and moderate for the summary assessment.
We have addressed a research gap by modifying and testing a tool to assess risk of study bias. Further research may be useful for assessing the applicability of the tool across different conditions.
Minor brain injury is a frequent condition. Validated clinical decision rules can help in deciding whether a computed tomogram (CT) of the head is required. We hypothesized that institutional guidelines are not frequently used, and that psychological factors are a common reason for ordering an unnecessary CT.
Physicians at the emergency department of a tertiary care hospital completed an anonymous questionnaire before ordering a CT of the head for a patient presenting with a GCS of 13-15 after a head trauma.
Over a period of 10 months, 1018 CTs of the head were performed in patients presenting with a GCS of 13-15 after a head trauma; 168 (16.5%) questionnaires were completed. The most four common reasons for ordering a CT were "to confirm/rule out traumatic intracranial lesion" (in 94% of all questionnaires), "to expedite diagnosis" (63%) "guidelines" (58%) and "fear of missing a traumatic intracranial lesion" (50%). A positive answer for "fear of being sued" was declared in 21%, and "pressure from the patient or his relatives" in 8% of all questionnaires. Of 71 questionnaires without "guidelines" as a positive answer, there were 40 (56%) positive answers of "fear of missing a traumatic cerebral lesion".
Besides guidelines, fear of missing a traumatic intracranial lesion played a role in ordering head CTs. Although the physicians had been instructed in the use of guidelines, including validated clinical decision rules, this did not prevent them from ordering unnecessary CTs.
CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary.
We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission >or=2 nights).
We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0) and sensitivity of 25/25 (100%, 86.3-100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99.95%, 99.81-99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations.
These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated.
The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.
There is much controversy about the use of computed tomography (CT) for patients with minor head injury. We aimed to develop a highly sensitive clinical decision rule for use of CT in patients with minor head injuries.
We carried out this prospective cohort study in the emergency departments of ten large Canadian hospitals and included consecutive adults who presented with a Glasgow Coma Scale (GCS) score of 13-15 after head injury. We did standardised clinical assessments before the CT scan. The main outcome measures were need for neurological intervention and clinically important brain injury on CT.
The 3121 patients had the following characteristics: mean age 38.7 years); GCS scores of 13 (3.5%), 14 (16.7%), 15 (79.8%); 8% had clinically important brain injury; and 1% required neurological intervention. We derived a CT head rule which consists of five high-risk factors (failure to reach GCS of 15 within 2 h, suspected open skull fracture, any sign of basal skull fracture, vomiting >2 episodes, or age >65 years) and two additional medium-risk factors (amnesia before impact >30 min and dangerous mechanism of injury). The high-risk factors were 100% sensitive (95% CI 92-100%) for predicting need for neurological intervention, and would require only 32% of patients to undergo CT. The medium-risk factors were 98.4% sensitive (95% CI 96-99%) and 49.6% specific for predicting clinically important brain injury, and would require only 54% of patients to undergo CT.
We have developed the Canadian CT Head Rule, a highly sensitive decision rule for use of CT. This rule has the potential to significantly standardise and improve the emergency management of patients with minor head injury.
Computed tomographic (CT) head scanning of blunt trauma patients is expensive, delays care, and necessitates radiation exposure, while detecting intracranial injuries in a minority of patients. Clinical characteristics may be able reliably identify patients who do not have intracranial injuries and consequently, do no require imaging.
Physicians assessed blunt trauma patients undergoing imaging for the presence or absence of specific criteria. Recursive partitioning was used to identify criteria that predict intracranial injuries with high sensitivity.
Intracranial injuries were found in 917 of 13,728 enrolled patients (6.7%). Injuries were rare among patients under age 65 who had no evidence of skull fracture, scalp hematoma, neurologic deficit, abnormal alertness, abnormal behavior, coagulopathy, or persistent vomiting. These characteristics would have identified 901 injury cases (sensitivity 98.3% [CI: 97.2-99.0]), while classifying 1,752 patients (12.8%) as "low risk."
Clinical characteristics can reliably identify patients who are unlikely to have intracranial injuries and who do not require CT imaging.