The cost-effectiveness of diagnostic management strategies for adults with minor head injury

Risk Factors Analysis for 90-Day Mortality of Adult Patients with Mild Traumatic Brain Injury in an Italian Emergency Department

Purpose: The most prominent risk factors for mortality after mild traumatic brain injury (TBI) have not been established. This study aimed to establish risk factors related to 90-day mortality after a traumatic event. Methods: A retrospective cohort study on adult patients entering the Emergency Department of the University Hospital of Trieste for mild TBI from 1 January 2020 to 31 December 2020 was conducted. Results: The final population was 1221 patients (median age of 78 years). The 90-day mortality rate was 7% (90 patients). In the Cox regression model (likelihood ratio 110.9; p < 2 × 10-16), the variables that significantly correlated to 90-day mortality were age (less than 75 years old is a protective factor, HR 0.29 [95%CI 0.16-0.54]; p < 0.001); chronic liver disease (HR 4.59 [95%CI 2.56-8.24], p < 0.001); cognitive impairment (HR 2.76 [95%CI 1.78-4.27], p < 0.001); intracerebral haemorrhage (HR 15.38 [95%CI 6.13-38.63], p < 0.001); and hospitalization (HR 2.56 [95%CI 1.67-3.92], p < 0.001). Cardiovascular disease (47% vs. 11%; p < 0.001) and cognitive impairment (36% vs. 10%; p < 0.001) were more prevalent in patients over 75 years of age than the rest of the population. Conclusions: In our cohort of patients with mild TBI, 90-day mortality was low but not negligible. The risk factors associated with 90-day mortality included age, history of chronic liver disease, and cognitive impairment, as well as evidence of intracerebral hemorrhage and hospitalization. The mortality of the sub-population of older patients was likely to be linked to cardiovascular comorbidities and neurodegenerative diseases.

Whole-brain traumatic controlled cortical impact to the left frontal lobe: Magnetic resonance image-based texture analysis

This research assesses the capability of texture analysis (TA) derived from high-resolution (HR) T2-weighted magnetic resonance imaging to identify primary sequelae following 1-5 hours of controlled cortical impact mild or severe traumatic brain injury (TBI) to the left frontal cortex (focal impact) and secondary (diffuse) sequelae in the right frontal cortex, bilateral corpus callosum, and hippocampus in rats. The TA technique comprised first-order (histogram-based) and second-order statistics (including gray-level co-occurrence matrix, gray-level run length matrix, and neighborhood gray-level difference matrix). Edema in the left frontal impact region developed within 1 hour and continued throughout the 5-hour assessments. The TA features from HR images confirmed the focal injury. There was no significant difference among radiomics features between the left and right corpus callosum or hippocampus from 1 to 5 hours following a mild or severe impact. The adjacent corpus callosum region and the distal hippocampus region (s), showed no diffuse injury 1-5 hours after mild or severe TBI. These results suggest that combining HR images with TA may enhance detection of early primary and secondary sequelae following TBI.

Clinical decision rules in predicting computed tomography scan findings and need for neurosurgical intervention in mild traumatic brain injury: a prospective observational study

PURPOSE

In this study, we will compare the diagnostic values of head CT decision rules in predicting the findings of CT scans in a prospective multicenter study in university emergency departments in Iran.

METHODS

The primary outcome was any traumatic lesion findings in brain CT scans, and the secondary outcomes were death, the need for mechanical ventilation, and neurosurgical intervention. Decision rules including the Canadian CT Head Rule (CCHR), New Orleans Criteria (NOC), National Institute for Health and Clinical Excellence (NICE), National Emergency X-Radiography Utilization Study (NEXUS), and Neurotraumatology Committee of the World Federation of Neurosurgical Societies (NCWFNS) were compared for the main outcomes.

RESULTS

In total, 434 mild TBI patients were enrolled in the study. The NCWFNS had the highest sensitivity (91.14%) and the lowest specificity (39.42%) for predicting abnormal finding in CT scan compared to other models. While the NICE obtained the lowest sensitivity (79.75%), it was associated with the highest specificity (66.67%). All model performances were improved when administered to predict neurosurgical intervention among patients with GCS 13-15. NEXUS (AUC 0.862, 95% CI 0.799-0.924) and NCWFNS (AUC 0.813, 95% CI 0.723-0.903) had the best performance among all evaluated models.

CONCLUSION

The NCWFNS and the NEXUS decision rules performed better than the CCHR and NICE guidelines for predicting any lesion in the CT imaging and neurosurgical intervention among patients with mTBI with GCS 13-15. For a subset of mTBI patients with GCS 15, the NOC criteria have higher sensitivity for abnormal CT imaging, but lower specificity and more requested CTs.

Adherence to the Canadian CT Head Rule in a Nova Scotian Emergency and Trauma Center

Background and aims Choosing Wisely Nova Scotia (CWNS), an affiliate of Choosing Wisely Canada (CWC), aims to address unnecessary care and tests through literature-informed lists developed by various disciplines. CWC has identified unnecessary head CTs among the top five tests, procedures, and treatments to question within the emergency department setting. The Canadian CT-scan Head Rule (CCHR) has been found to be the most effective clinical decision rule in adults with minor head injuries. This study aimed 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. Materials and methods Our mixed methods design included a narrative literature review, a retrospective chart audit, and a qualitative audit-feedback component with physicians who work in the emergency department (ED). The chart audit applied the guidelines for adherence to the CCHR and reported on the level of compliance within the ED. Results Analysis of qualitative data is included here, in parallel with in-depth analysis to contextualize findings from the chart audit. A total of 302 charts of patients presenting to the surveyed site were retrospectively reviewed for this study. Of the 37 cases where the 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 as per the CCHR, 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. Conclusions Our review revealed that the CCHR was adhered in 87.8% of cases at the surveyed ED. Identifying contextual factors that facilitate or hinder the application of CCHR in practice is critical to achieving the goal of reducing unnecessary CTs. This work will be presented to the physician group to engage and understand factors that are enablers in the process of ED minor head injury care.

Performance of a new portable near-infrared spectroscopy device for detection of traumatic intracranial hematoma

INTRODUCTION

We report results of a newly developed portable near-infrared spectroscopy (NIRS) based point-of-care device CEREBO® to detect traumatic intracranial hematoma (TICH).

MATERIALS AND METHODS

Patients with alleged history of head injury visiting emergency room were enrolled. They were examined consecutively for the presence of TICH using CEREBO® and computed tomography (CT) scans.

RESULTS

A total of 158 participants and 944 lobes were scanned, and 18% of lobes were found to have TICH on imaging with computed tomography of the head. 33.9% of the lobes could not be scanned due to scalp lacerations. The mean depth of hematoma was 0.8 (SD 0.5) cm and the mean volume of the hematoma was 7.8 (11.3) cc. The overall sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of CEREBO® to classify subjects as hemorrhagic or non-hemorrhagic were 96% (CI 90 - 99%), 85% (CI 73 - 93%), 92% (CI 86 - 96%), 91% (CI 84 - 96%) and 93% (CI 82 - 98%) whereas to classify the lobes as hemorrhagic and non-hemorrhagic, the sensitivity, specificity, accuracy, PPV and NPV were 93% (CI 88 - 96%), 90% (CI 87 - 92%), 90% (CI 88 - 92%), 66% (CI 61 - 73%), and 98% (CI 97 - 99%) respectively. The sensitivity was highest at 100% (CI 92 - 100%) for the detection of extradural and subdural hematoma. The sensitivity for detecting intracranial hematoma including epidural, subdural, intracerebral and subarachnoid hematomas, of more than 2 cc was 97% (CI 93 - 99%) and the NPV was 100% (CI 99 - 100%). The sensitivity dropped for hematomas less than 2cc in volume to 84% (CI 71 - 92%) and the NPV was 99% (CI 98 - 99%). The sensitivity to detect bilateral hematomas was 94% (CI 74 - 99%).

CONCLUSION

The performance of currently tested NIRS device for detection of TICH was good and can be considered for triaging a patient requiring a CT scan of the head after injury. The NIRS device can efficiently detect traumatic unilateral hematomas as well as those bilateral hematomas where the volumetric difference is greater than 2cc.

The use of head computerized tomography in patients with GCS 15 following trauma: Less is more

INTRODUCTION

Computerized tomography (CT) imaging is a standard part of traumatic brain injury (TBI) evaluation but not all patients require it after mild head injury. Given the increasing incidence of TBI in the United States, there is an urgent need to better characterize CT head imaging utilization in evaluating trauma patients, especially patients at low risk of requiring intervention, such as those presenting with a normal GCS.

METHODS

We analyzed the 2017-2019 National Trauma Databank using ICD-10 codes to identify patients who received a head CT. We used Abbreviated Injury Scale (AIS) scores to identify patients with a moderate to severe head injury defined as an AIS severity ≥ 3. Procedural TBI management was defined as having an intracranial monitor or operative decompression. We used a modified Poisson modeling to identify risk factors for a moderate/severe TBI and risk factors for undergoing procedural management among patients with head CT and GCS 15.

RESULTS

Of 2,850,036 patients, 1,502,039 (52.7%) had a head CT. Among patients who had a head CT, 1,078,093 patients (74.9%) had a GCS 15 on arrival. Of this group, only 16.6% (n = 176,431) had a moderate/severe head injury. For those with moderate/severe head injury, 6.0% (n = 10,544/176,431) of patients underwent procedural head injury management. Risk factors for undergoing procedural head injury management included: isolated head injury (RR 2.43, 95% CI 2.34, 2.53), male sex (RR 1.73, 95% CI 1.67, 1.80), age > 50 years (RR 1.39 95% CI 1.32, 1.47), falls (RR 1.28, 95% CI 1.22, 1.35), and the use of anti-coagulation (RR 1.16, 95% CI 1.11, 1.21).

CONCLUSION

Few patients had moderate/severe head injury when presenting with a GCS 15. However, patients ≥ 50 years, men, and those who suffered falls were at higher risk. Anti-coagulation use was not associated with moderate/severe head injury but did increase the risk of procedural TBI management. Given the cost and associated radiation, reducing CT utilization for younger patients while using a more liberal head CT strategy for high-risk patients may provide substantial patient value.

Economic Evaluation of In-Hospital Clinical Practices in Acute Injury Care: A Systematic Review

OBJECTIVES

Underuse of high-value clinical practices and overuse of low-value practices are major sources of inefficiencies in modern healthcare systems. To achieve value-based care, guidelines and recommendations should target both underuse and overuse and be supported by evidence from economic evaluations. We aimed to conduct a systematic review of the economic value of in-hospital clinical practices in acute injury care to advance knowledge on value-based care in this patient population.

METHODS

Pairs of independent reviewers systematically searched MEDLINE, Embase, Web of Science, and Cochrane Central Register for full economic evaluations of in-hospital clinical practices in acute trauma care published from 2009 to 2019 (last updated on June 17, 2020). Results were converted into incremental net monetary benefit and were summarized with forest plots. The protocol was registered with PROSPERO (CRD42020164494).

RESULTS

Of 33 910 unique citations, 75 studies met our inclusion criteria. We identified 62 cost-utility, 8 cost-effectiveness, and 5 cost-minimization studies. Values of incremental net monetary benefit ranged from international dollars -467 000 to international dollars 194 000. Of 114 clinical interventions evaluated (vs comparators), 56 were cost-effective. We identified 15 cost-effective interventions in emergency medicine, 6 in critical care medicine, and 35 in orthopedic medicine. A total of 58 studies were classified as high quality and 17 as moderate quality. From studies with a high level of evidence (randomized controlled trials), 4 interventions were clearly dominant and 8 were dominated.

CONCLUSIONS

This research advances knowledge on value-based care for injury admissions. Results suggest that almost half of clinical interventions in acute injury care that have been studied may not be cost-effective.

Adherence to Clinical Practice Guideline Recommendations on Low-Value Injury Care: A Multicenter Retrospective Cohort Study

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.

Socio-Economic Disparities in Access to Diagnostic Neuroimaging Services in the United Kingdom: A Systematic Review

Socio-economic factors affecting health care can lead to delays in diagnosis of neurological conditions, consequentially affecting treatment and morbidity rates. This inequality in health care can leave patients from lower socio-economic backgrounds more vulnerable to a poorer quality of care from health care providers in the United Kingdom (U.K.). Aims: In this systematic review, we assess the impact of socio-economic status on the use of diagnostic neuroimaging in the U.K., measured by the timeliness, accessibility and appropriate use of computed tomography (CT), magnetic resonance imaging (MRI), ultrasonography, electroencephalography (EEG) and single-photon emission computed tomography (SPECT). We specifically evaluate the non-surgical use of neuroimaging techniques as this relies on the judgment of primary care-givers (e.g., doctors and radiologists), where health disparities are most common. This study includes the analysis of diagnostic imaging used for dementia, minor head injury, stroke, cancer, epilepsy, chronic inflammatory demyelinating polyneuropathy and Parkinson’s disease. With this study, we aim to assess the health inequalities at disease diagnosis. Methods: Using Medline (via Ovid), PubMed and Web of Science databases as sources of information, we critically appraise existing studies on neuroimaging use in the U.K. health care system, published between January 2010 and February 2021. Findings: A total of 18 studies were included in this research, revealing that there was an increase in patients of Black and Asian communities diagnosed with dementia and at an earlier age. There was little evidence to suggest that a lack of access to diagnostic imaging is associated with socio-economic status. However, there are data to suggest that people of a lower socio-economic background require more specialist services with diagnostic neuroimaging tools. In addition, there is evidence to suggest that diagnostic neuroimaging techniques could be utilised more effectively by health care workers to prevent unnecessary delays in diagnosis for patients in lower socio-economic areas.

ACR Appropriateness Criteria® Head Trauma: 2021 Update

Head trauma (ie, head injury) is a significant public health concern and is a leading cause of morbidity and mortality in children and young adults. Neuroimaging plays an important role in the management of head and brain injury, which can be separated into acute (0-7 days), subacute (<3 months), then chronic (>3 months) phases. Over 75% of acute head trauma is classified as mild, of which over 75% have a normal Glasgow Coma Scale score of 15, therefore clinical practice guidelines universally recommend selective CT scanning in this patient population, which is often based on clinical decision rules. While CT is considered the first-line imaging modality for suspected intracranial injury, MRI is useful when there are persistent neurologic deficits that remain unexplained after CT, especially in the subacute or chronic phase. Regardless of time frame, head trauma with suspected vascular injury or suspected cerebrospinal fluid leak should also be evaluated with CT angiography or thin-section CT imaging of the skull base, respectively. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

A cross-sectional study reporting concussion exposure, assessment and management in Western Australian general practice

Background

General Practitioners (GPs) may be called upon to assess patients who have sustained a concussion despite limited information being available at this assessment. Information relating to how concussion is actually being assessed and managed in General Practice is scarce. This study aimed to identify characteristics of current Western Australian (WA) GP exposure to patients with concussion, factors associated with GPs’ knowledge of concussion, confidence of GPs in diagnosing and managing patients with concussion, typical referral practices and familiarity of GPs with guidelines.

Methods

In this cross-sectional study, GPs in WA were recruited via the RACGP WA newsletter and shareGP and the consented GPs completed an electronic survey. Associations were performed using Chi-squared tests or Fisher’s Exact test.

Results

Sixty-six GPs in WA responded to the survey (response rate = 1.7%). Demographics, usual practice, knowledge, confidence, identification of prolonged recovery as well as guideline and resource awareness of GPs who practised in regional and metropolitan areas were comparable (p > 0.05). Characteristics of GPs were similar between those who identified all symptoms of concussion and distractors correctly and those who did not (p > 0.05). However, 84% of the respondents who had never heard of concussion guidelines were less likely to answer all symptoms and distractors correctly (p = 0.039). Whilst 78% of the GPs who were confident in their diagnoses had heard of guidelines (p = 0.029), confidence in managing concussion was not significantly associated with GPs exposure to guidelines. It should be noted that none of the respondents correctly identified signs of concussion and excluded the distractors.

Conclusions

Knowledge surrounding concussion guidelines, diagnosis and management varied across GPs in WA. Promotion of available concussion guidelines may assist GPs who lack confidence in making a diagnosis. The lack of association between GPs exposure to guidelines and confidence managing concussion highlights that concussion management may be an area where GPs could benefit from additional education and support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01384-1.

A Review of the Role of Auditory Evoked Potentials in Mild Traumatic Brain Injury Assessment

Around 75% to 90% of people who experience a traumatic brain injury (TBI) are classified as having a mild TBI (mTBI). The term mTBI is synonymous with concussion or mild head injury (MHI) and is characterized by symptoms of headache, nausea, dizziness, and blurred vision. Problems in cognitive abilities such as deficits in memory, processing speed, executive functioning, and attention are also considered symptoms of mTBI. Since these symptoms are subtle in nature and may not appear immediately following the injury, mTBI is often undetected on conventional neuropsychological tests. Current neuroimaging techniques may not be sensitive enough in identifying the array of microscopic neuroanatomical and subtle neurophysiological changes following mTBI. To this end, electrophysiological tests, such as auditory evoked potentials (AEPs), can be used as sensitive tools in tracking physiological changes underlying physical and cognitive symptoms associated with mTBI. The purpose of this review article is to examine the body of literature describing the application of AEPs in the assessment of mTBI and to explore various parameters of AEPs which may hold diagnostic value in predicting positive rehabilitative outcomes for people with mTBI.

The Applicability of New Orleans Criteria for Head Computed Tomography in Inpatient Falls With Injury

Background

Inpatient falls are a patient safety concern. Limited data exist on the utility of head computed tomography (CT) for inpatient falls. The New Orleans Criteria (NOC) is a validated tool to determine the appropriateness of neuroimaging in the emergency department for falls with minor head injury. This study aimed to evaluate whether the NOC could be applied to inpatient falls.

Methods

This retrospective cohort study assessed 1 year of inpatient falls with injury at 5 inpatient facilities. Records were reviewed for demographic data, fall circumstances, laboratory results, components of the NOC, and head CT results. Cohorts included positive NOC (≥1 NOC finding) and negative NOC. Sensitivity and specificity were calculated for the NOC alone, NOC plus coagulopathy, and NOC or coagulopathy for acute intracranial process.

Results

Of 332 inpatient falls with injury, 188 (57%) received a head CT. Of the 250 (75.3%) NOC-positive cases, 159 (63.6%) received a head CT. Of all patients who received a head CT, 7 (2.1%) showed a significant acute intracranial process. The NOC was positive in 6 of the 7 cases (sensitivity 85.7% and specificity 23.8%); the other case had a significant coagulopathy. New Orleans Criteria or coagulopathy had 100% sensitivity and 23.4% specificity.

Conclusions

Our findings show that use of the NOC to evaluate potential intracranial injury in inpatient falls is limited. Adding criteria to the NOC may improve its test characteristics, with a sensitivity of 100% for the NOC or coagulopathy, suggesting potential clinical utility.

Impact of guidelines for the management of minor head injury on the utilization and diagnostic yield of CT over two decades, using natural language processing in a large dataset

Objectives

We investigated the impact of clinical guidelines for the management of minor head injury on utilization and diagnostic yield of head CT over two decades.

Methods

Retrospective before-after study using multiple electronic health record data sources. Natural language processing algorithms were developed to rapidly extract indication, Glasgow Coma Scale, and CT outcome from clinical records, creating two datasets: one based on all head injury CTs from 1997 to 2009 (n = 9109), for which diagnostic yield of intracranial traumatic findings was calculated. The second dataset (2009–2014) used both CT reports and clinical notes from the emergency department, enabling selection of minor head injury patients (n = 4554) and calculation of both CT utilization and diagnostic yield. Additionally, we tested for significant changes in utilization and yield after guideline implementation in 2011, using chi-square statistics and logistic regression.

Results

The yield was initially nearly 60%, but in a decreasing trend dropped below 20% when CT became routinely used for head trauma. Between 2009 and 2014, of 4554 minor head injury patients overall, 85.4% underwent head CT. After guideline implementation in 2011, CT utilization significantly increased from 81.6 to 87.6% (p = 7 × 10⁻⁷), while yield significantly decreased from 12.2 to 9.6% (p = 0.029).

Conclusions

The number of CTs performed for head trauma gradually increased over two decades, while the yield decreased. In 2011, despite implementation of a guideline aiming to improve selective use of CT in minor head injury, utilization significantly increased.

Key Points

• Over two decades, the number of head CTs performed for minor, moderate, and severe head injury gradually increased, while the diagnostic yield for intracranial findings showed a decreasing trend.

• Despite the implementation of a guideline in 2011, aiming to improve selective use of CT in minor head injury, utilization significantly increased, while diagnostic yield significantly decreased.

• Natural language processing is a valuable tool to monitor the utilization and diagnostic yield of imaging as a potential quality-of-care indicator.

Electronic supplementary material

The online version of this article (10.1007/s00330-018-5954-5) contains supplementary material, which is available to authorized users.

Economic evaluation of the NET intervention versus guideline dissemination for management of mild head injury in hospital emergency departments

BACKGROUND

Evidence-based guidelines for the management of mild traumatic brain injury (mTBI) in the emergency department (ED) are now widely available, and yet, clinical practice remains inconsistent with the guidelines. The Neurotrauma Evidence Translation (NET) intervention was developed to increase the uptake of guideline recommendations and improve the management of minor head injury in Australian emergency departments (EDs). However, the adoption of this type of intervention typically entails an upfront investment that may or may not be fully offset by improvements in clinical practice, health outcomes and/or reductions in health service utilisation. The present study estimates the cost and cost-effectiveness of the NET intervention, as compared to the passive dissemination of the guideline, to evaluate whether any improvements in clinical practice or health outcomes due to the NET intervention can be obtained at an acceptable cost.

METHODS AND FINDINGS

Study setting: The NET cluster randomised controlled trial [ACTRN12612001286831].

STUDY SAMPLE

Seventeen EDs were randomised to the control condition and 14 to the intervention. One thousand nine hundred forty-three patients were included in the analysis of clinical practice outcomes (NET sample). A total of 343 patients from 14 control and 10 intervention EDs participated in follow-up interviews and were included in the analysis of patient-reported health outcomes (NET-Plus sample).

OUTCOME MEASURES

Appropriate post-traumatic amnesia (PTA) screening in the ED (primary outcome). Secondary clinical practice outcomes: provision of written information on discharge (INFO) and safe discharge (defined as CT scan appropriately provided plus PTA plus INFO). Secondary patient-reported, post-discharge health outcomes: anxiety (Hospital Anxiety and Depression Scale), post-concussive symptoms (Rivermead), and preference-based health-related quality of life (SF6D).

METHODS

Trial-based economic evaluations from a health sector perspective, with time horizons set to coincide with the final follow-up for the NET sample (2 months post-intervention) and to 1-month post-discharge for the NET-Plus sample.

RESULTS

Intervention and control groups were not significantly different in health service utilisation received in the ED/inpatient ward following the initial mTBI presentation (adjusted mean difference $23.86 per patient; 95%CI - $106, $153; p = 0.719) or over the longer follow-up in the NET-plus sample (adjusted mean difference $341.78 per patient; 95%CI - $58, $742; p = 0.094). Savings from lower health service utilisation are therefore unlikely to offset the significantly higher upfront cost of the intervention (mean difference $138.20 per patient; 95%CI $135, $141; p < 0.000). Estimates of the net effect of the intervention on total cost (intervention cost net of health service utilisation) suggest that the intervention entails significantly higher costs than the control condition (adjusted mean difference $169.89 per patient; 95%CI $43, $297, p = 0.009). This effect is larger in absolute magnitude over the longer follow-up in the NET-plus sample (adjusted mean difference $505.06; 95%CI $96, $915; p = 0.016), mostly due to additional health service utilisation. For the primary outcome, the NET intervention is more costly and more effective than passive dissemination; entailing an additional cost of $1246 per additional patient appropriately screened for PTA ($169.89/0.1363; Fieller's 95%CI $525, $2055). For NET to be considered cost-effective with 95% confidence, decision-makers would need to be willing to trade one quality-adjusted life year (QALY) for 25 additional patients appropriately screened for PTA. While these results reflect our best estimate of cost-effectiveness given the data, it is possible that a NET intervention that has been scaled and streamlined ready for wider roll-out may be more or less cost-effective than the NET intervention as delivered in the trial.

CONCLUSIONS

While the NET intervention does improve the management of mTBI in the ED, it also entails a significant increase in cost and-as delivered in the trial-is unlikely to be cost-effective at currently accepted funding thresholds. There may be a scope for a scaled-up and streamlined NET intervention to achieve a better balance between costs and outcomes.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12612001286831 , date registered 12 December 2012.

An Evaluation of the ACEP Guideline for Mild Head Injuries in Taiwan

Introduction

Traumatic brain injury (TBI) is an important issue in the emergency department. In the United States, the American College of Emergency Physicians (ACEP) published clinical guideline to select patients with mild head injuries for head computed tomography (CT) scans in 2008. The aim of this study was to identify the possible benefits of compliance with these guidelines for mild head injury patients in Taiwan.

Method

This was a secondary analysis on our previous study published for association of hypertension and head injuries. In our previous study, we collected data about 1290 patients with head injuries who received brain CT scans in the emergency department from September 2012 to August 2013 for a study regarding the association between head injury and hypertension. In present study, we subjected this data to further analysis to try to validate the ACEP clinical policy for mild head injuries.

Results

Of these 1,290 patients, 154 were found to have brain haemorrhage on the initial brain CT scan, and 5 were in need of neurosurgical intervention. A total of 859 patients met the ACEP guideline criteria, and 117 of these had brain haemorrhages. The sensitivity and specificity of the ACEP guideline to predict brain haemorrhage were 75.97% (95% confidence interval [CI], 68.44% to 82.48%) and 34.68% (95% CI, 31.91% to 37.53%), respectively. In predicting neurosurgical intervention, the sensitivity and specificity of the guideline were 100% (95% CI, 47.82% to 100%) and 33.54% (95% CI, 30.96% to 36.2%), respectively.

Conclusion

Although adoption of the ACEP clinical policy may reduce the number of brain CT scans in mild head injury patients who may need neurosurgical interventions, it is not a good selection tool in Taiwan.

Should all anticoagulated patients with head injury receive a CT scan? Decision-analysis modelling of an observational cohort

OBJECTIVES

It is not currently clear whether all anticoagulated patients with a head injury should receive CT scanning or only those with evidence of traumatic brain injury (eg, loss of consciousness or amnesia). We aimed to determine the cost-effectiveness of CT for all compared with selective CT use for anticoagulated patients with a head injury.

DESIGN

Decision-analysis modelling of data from a multicentre observational study.

SETTING

33 emergency departments in England and Scotland.

PARTICIPANTS

3566 adults (aged ≥16 years) who had suffered blunt head injury, were taking warfarin and underwent selective CT scanning.

MAIN OUTCOME MEASURES

Estimated expected benefits in terms of quality-adjusted life years (QALYs) were the entire cohort to receive a CT scan; estimated increased costs of CT and also the potential cost implications associated with patient survival and improved health. These values were used to estimate the cost per QALY of implementing a strategy of CT for all patients compared with observed practice based on guidelines recommending selective CT use.

RESULTS

Of the 1420 of 3534 patients (40%) who did not receive a CT scan, 7 (0.5%) suffered a potentially avoidable head injury-related adverse outcome. If CT scanning had been performed in all patients, appropriate treatment could have gained 3.41 additional QALYs but would have incurred £193 149 additional treatment costs and £130 683 additional CT costs. The incremental cost-effectiveness ratio of £94 895/QALY gained for unselective compared with selective CT use is markedly above the threshold of £20-30 000/QALY used by the UK National Institute for Care Excellence to determine cost-effectiveness.

CONCLUSIONS

CT scanning for all anticoagulated patients with head injury is not cost-effective compared with selective use of CT scanning based on guidelines recommending scanning only for those with evidence of traumatic brain injury.

TRIAL REGISTRATION NUMBER

NCT 02461498.

Different Imaging Strategies in Patients With Possible Basilar Artery Occlusion: Cost-Effectiveness Analysis

BACKGROUND AND PURPOSE

This study evaluated the cost-effectiveness of different noninvasive imaging strategies in patients with possible basilar artery occlusion.

METHODS

A Markov decision analytic model was used to evaluate long-term outcomes resulting from strategies using computed tomographic angiography (CTA), magnetic resonance imaging, nonenhanced CT, or duplex ultrasound with intravenous (IV) thrombolysis being administered after positive findings. The analysis was performed from the societal perspective based on US recommendations. Input parameters were derived from the literature. Costs were obtained from United States costing sources and published literature. Outcomes were lifetime costs, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios, and net monetary benefits, with a willingness-to-pay threshold of $80,000 per QALY. The strategy with the highest net monetary benefit was considered the most cost-effective. Extensive deterministic and probabilistic sensitivity analyses were performed to explore the effect of varying parameter values.

RESULTS

In the reference case analysis, CTA dominated all other imaging strategies. CTA yielded 0.02 QALYs more than magnetic resonance imaging and 0.04 QALYs more than duplex ultrasound followed by CTA. At a willingness-to-pay threshold of $80,000 per QALY, CTA yielded the highest net monetary benefits. The probability that CTA is cost-effective was 96% at a willingness-to-pay threshold of $80,000/QALY. Sensitivity analyses showed that duplex ultrasound was cost-effective only for a prior probability of ≤0.02 and that these results were only minimally influenced by duplex ultrasound sensitivity and specificity. Nonenhanced CT and magnetic resonance imaging never became the most cost-effective strategy.

CONCLUSIONS

Our results suggest that CTA in patients with possible basilar artery occlusion is cost-effective.

Cost-effectiveness of the PECARN rules in children with minor head trauma

STUDY OBJECTIVE

To improve the efficiency and appropriateness of computed tomography (CT) use in children with minor head trauma, clinical prediction rules were derived and validated by the Pediatric Emergency Care Applied Research Network (PECARN). The objective of this study was to conduct a cost-effectiveness analysis comparing the PECARN traumatic brain injury prediction rules to usual care for selective CT use.

METHODS

We used decision analytic modeling to project the outcomes, costs, and cost-effectiveness of applying the PECARN rules compared with usual care in a hypothetical cohort of 1,000 children with minor blunt head trauma. Clinical management was directed by level of risk as specified by the presence or absence of variables in the PECARN traumatic brain injury prediction rules. Immediate costs of care (diagnostic testing, treatment [not including clinician time], and hospital stay) were derived on single-center data. Quality-adjusted life-year losses related to the sequelae of clinically important traumatic brain injuries and to radiation-induced cancers, number of CT scans, number of radiation-induced cancers, number of missed clinically important traumatic brain injury, and total costs were evaluated.

RESULTS

Compared with the usual care strategy, the PECARN strategy was projected to miss slightly more children with clinically important traumatic brain injuries (0.26 versus 0.02 per 1,000 children) but used fewer cranial CT scans (274 versus 353), resulted in fewer radiation-induced cancers (0.34 versus 0.45), cost less ($904,940 versus $954,420), and had lower net quality-adjusted life-year loss (-4.64 versus -5.79). Because the PECARN strategy was more effective (less quality-adjusted life-year loss) and less costly, it dominated the usual care strategy. Results were robust under sensitivity analyses.

CONCLUSION

Application of the PECARN traumatic brain injury prediction rules for children with minor head trauma would lead to beneficial outcomes and more cost-effective care.

Implementing evidence-based recommended practices for the management of patients with mild traumatic brain injuries in Australian emergency care departments: study protocol for a cluster randomised controlled trial

Background

Mild head injuries commonly present to emergency departments. The challenges facing clinicians in emergency departments include identifying which patients have traumatic brain injury, and which patients can safely be sent home. Traumatic brain injuries may exist with subtle symptoms or signs, but can still lead to adverse outcomes. Despite the existence of several high quality clinical practice guidelines, internationally and in Australia, research shows inconsistent implementation of these recommendations. The aim of this trial is to test the effectiveness of a targeted, theory- and evidence-informed implementation intervention to increase the uptake of three key clinical recommendations regarding the emergency department management of adult patients (18 years of age or older) who present following mild head injuries (concussion), compared with passive dissemination of these recommendations. The primary objective is to establish whether the intervention is effective in increasing the percentage of patients for which appropriate post-traumatic amnesia screening is performed.

Methods/design

The design of this study is a cluster randomised trial. We aim to include 34 Australian 24-hour emergency departments, which will be randomised to an intervention or control group. Control group departments will receive a copy of the most recent Australian evidence-based clinical practice guideline on the acute management of patients with mild head injuries. The intervention group will receive an implementation intervention based on an analysis of influencing factors, which include local stakeholder meetings, identification of nursing and medical opinion leaders in each site, a train-the-trainer day and standardised education and interactive workshops delivered by the opinion leaders during a 3 month period of time. Clinical practice outcomes will be collected retrospectively from medical records by independent chart auditors over the 2 month period following intervention delivery (patient level outcomes). In consenting hospitals, eligible patients will be recruited for a follow-up telephone interview conducted by trained researchers. A cost-effectiveness analysis and process evaluation using mixed-methods will be conducted. Sample size calculations are based on including 30 patients on average per department. Outcome assessors will be blinded to group allocation.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12612001286831 (date registered 12 December 2012).

The Impact of Computed Tomography of the Chest on the Management of Patients in a Medical Intensive Care Unit

PURPOSE

To understand whether chest computed tomographies (CTs) have utility in a medical intensive care unit (MICU) population as previously noted in nonmedical critically ill patients.

PATIENTS AND METHODS

We conducted a retrospective cohort study of patients receiving chest CTs in the MICU at an urban, academic institution. Indications for, findings on, and care changes made after chest CT were obtained. We identified patient characteristics associated with having a care change clearly related to the CT using multivariate regression.

RESULTS

We evaluated 134 patients; 64 (47.8%) had a chest CT with intravenous contrast. Common findings included pulmonary consolidation (46.3%), nonconsolidative pulmonary parenchymal disease (29.1%), and pleural effusion (35.1%). Of the chest CTs, 23.9% were followed by changes in management clearly related to the study. Use of intravenous contrast was associated with increased odds of having a care change (adjusted odds ratio [95% confidence interval [CI] versus noncontrast study: 3.14 [1.18-8.37], P = .022) and having the CT performed 1 or 2 days after ICU admission versus on the day of ICU admission was associated with lower odds of a care change (odds ratio [95% CI]: 0.29 [0.09-0.99], P = .048).

CONCLUSION

Less than one-quarter of chest CTs in the MICU result in management. Intravenous contrast-enhanced CTs and CTs done on the day of ICU admission have increased odds of utility.

Neuroimaging after mild traumatic brain injury: review and meta-analysis

This paper broadly reviews the study of mild traumatic brain injury (mTBI), across the spectrum of neuroimaging modalities. Among the range of imaging methods, however, magnetic resonance imaging (MRI) is unique in its applicability to studying both structure and function. Thus we additionally performed meta-analyses of MRI results to examine 1) the issue of anatomical variability and consistency for functional MRI (fMRI) findings, 2) the analogous issue of anatomical consistency for white-matter findings, and 3) the importance of accounting for the time post injury in diffusion weighted imaging reports. As we discuss, the human neuroimaging literature consists of both small and large studies spanning acute to chronic time points that have examined both structural and functional changes with mTBI, using virtually every available medical imaging modality. Two key commonalities have been used across the majority of imaging studies. The first is the comparison between mTBI and control populations. The second is the attempt to link imaging results with neuropsychological assessments. Our fMRI meta-analysis demonstrates a frontal vulnerability to mTBI, demonstrated by decreased signal in prefrontal cortex compared to controls. This vulnerability is further highlighted by examining the frequency of reported mTBI white matter anisotropy, in which we show a strong anterior-to-posterior gradient (with anterior regions being more frequently reported in mTBI). Our final DTI meta-analysis examines a debated topic arising from inconsistent anisotropy findings across studies. Our results support the hypothesis that acute mTBI is associated with elevated anisotropy values and chronic mTBI complaints are correlated with depressed anisotropy. Thus, this review and set of meta-analyses demonstrate several important points about the ongoing use of neuroimaging to understand the functional and structural changes that occur throughout the time course of mTBI recovery. Based on the complexity of mTBI, however, much more work in this area is required to characterize injury mechanisms and recovery factors and to achieve clinically-relevant capabilities for diagnosis.

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mTBI neuroimaging literature review and meta-analyses of fMRI and DTI.

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fMRI meta-analysis revealed differences between mTBI and controls in 13 regions.

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mTBI anisotropy findings are statistically more frequently reported in anterior regions.

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Anisotropy is elevated in acute mTBI, but depressed in chronic mTBI.

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We hypothesize a statistical interaction between anisotropy, cognitive score, and time.

The cost-effectiveness of diagnostic management strategies for children with minor head injury

AIM

To estimate the cost-effectiveness of diagnostic management strategies for children with minor head injury and identify an optimal strategy.

METHODS

A probabilistic decision analysis model was developed to estimate the costs and quality-adjusted life years (QALYs) accrued by each of six potential management strategies for minor head injury, including a theoretical 'zero option' strategy of discharging all patients home without investigation. The model took a lifetime horizon and the perspective of the National Health Service.

RESULTS

The optimal strategy was based on the Children's Head injury Algorithm for the prediction of Important Clinical Events (CHALICE) rule, although the costs and outcomes associated with each strategy were broadly similar.

CONCLUSIONS

Liberal use of CT scanning based on a high sensitivity decision rule is not only effective but also cost saving, with the CHALICE rule being the optimal strategy, although there is some uncertainty in the results. Incremental changes in the costs and QALYs are very small when all selective CT strategies are compared. The estimated cost of caring for patients with brain injury worsened by delayed treatment is very high compared with the cost of CT scanning. This analysis suggests that all hospitals receiving children with minor head injury should have unrestricted access to CT scanning for use in conjunction with evidence-based guidelines.

Efficacy of Canadian computed tomography head rule in predicting the need for a computed-axial tomography scans among patients with suspected head injuries

Context:

The use of imaging modalities is crucial in the diagnostic field of critical medicine. However, the ethical and economic use of these techniques has become a major concern especially in resource-poor settings. The Canadian computed tomography Head Rule (CCHR) is being increasingly used all over the world to evaluate the necessity of a Computer-assisted Tomography (CT) scan in patients with suspected head injury.

Aim:

The aim of the current study is to evaluate the efficacy of CCHR to predict the occurrence of head injury, as evidenced radiologically by a CT Head, at a government tertiary care clinical setting in south India.

Setting and Design:

The design was that of a hospital-based cross-sectional survey conducted at the Medical College Hospital, Thiruvananthapuram (Kerala, India).

Materials and Methods:

The study subjects were patients with suspected head injury evaluated at the Surgical Casualty Department of the study setting. Fifty consecutive patients with suspected head injury were enrolled in the study.

Statistical Analysis:

The Chi-square test was used to assess the statistical significance of association between the outcome variable and the exposure characteristics. The diagnostic ability of the Glasgow Coma Scale (GCS) and CCHR were expressed in terms of sensitivity and specificity by considering CT diagnosed Head injury as the gold standard diagnostic tool.

Results:

Clinical manifestations as measured by a GCS score < 13 failed to significantly predict a head injury in the CT scan. However, the same became statistically significant when the CCHR was added to the GCS score as a predictor (P value < 0.001). The sensitivity of the tool in predicting a head injury rose from 23.3 to 96.7%.

Conclusion:

The current study suggested that the CCHR could act as an excellent decision rule to indicate the need of a CT scan. The need of a decision rule was warranted in the context of the growth of newer diagnostic imaging facilities in India.

Evaluation of the Scandinavian guidelines for head injuries based on a consecutive series with computed tomography from a Norwegian university hospital

Background

This study prospectively assesses clinical characteristics and management of consecutive minimal, mild and moderate head injury patients referred for CT scans. Compliance with the Scandinavian head injury guidelines and possible reasons for non-compliance is explored.

Methods

From January 16^th 2006 to January 15^th 2007, 1325 computed tomography (CT) examinations due to minimal, mild or moderate head injury according to the Head Injury Severity Scale (HISS) were carried out at our University Hospital. When ordering a CT scan due to head trauma, physicians were asked to fill out a questionnaire.

Results

Guideline compliance was impossible to assess in 49.5% of all cases. This was due to non-assessable or missing key variables necessary in the decision making algorithm. One or more key variables for HISS classification were not assessable in 34.4% as it was unknown whether there had been loss of consciousness (LOC), duration of LOC was unknown or it was impossible to assess amnesia or focal neurologic deficits. Definite compliance with both CT and admittance recommendations in guidelines was seen in only 31.2%. In 54.2% of patients with minimal head injuries who underwent CT scans, imaging was not necessary according to guidelines. 59.1% of all patients were admitted to hospital, however only 23.7% of these were admitted because of the head-injury alone. Age < 4 years, possible medical cause of injuries, severe headache/nausea or vomiting and the presence of non-traumatic CT findings were independently associated with non-assessable compliance with Scandinavian guidelines. Suspicion of influence of alcohol was inversely associated to non-compliance.

Conclusions

Despite the prospective study design, guideline compliance was not assessable in nearly half of the patients. Patients with isolated head injuries and available and obtainable complete clinical information necessary for guideline-based decision making are not dominating in a head injury population.