Intent of health care providers to adopt a clinical decision support tool in the management of minor pediatric head injuries

Neuroimaging for mild traumatic brain injury in children: cross-sectional study using national claims data

BACKGROUND

Current guidelines recommend healthcare professionals avoid routine use of neuroimaging for diagnosing mild traumatic brain injury (mTBI).

OBJECTIVE

This study aimed to examine current use of CT and MRI among children and young adult patients with mTBI and factors that increase likelihood of neuroimaging in this population.

MATERIALS AND METHODS

Data were analyzed using the 2019 MarketScan commercial claims and encounters database for the commercially insured population for both inpatient and outpatient claims. Descriptive statistics and logistic regression models for patients  ≤24 years of age who received an ICD-10-CM code indicative of a possible mTBI were analyzed.

RESULTS

Neuroimaging was performed in 16.9% (CT; 95% CI=16.7-17.1) and 0.9% (MRI; 95% CI=0.8-0.9) of mTBI outpatient visits (including emergency department visits) among children (≤18 years old). Neuroimaging was performed in a higher percentage of outpatient visits for patients 19-24 years old (CT=47.1% [95% CI=46.5-47.6] and MRI=1.7% [95% CI=1.5-1.8]), and children aged 15-18 years old (CT=20.9% [95% CI=20.5-21.2] and MRI=1.4% [95% CI=1.3-1.5]). Outpatient visits for males were 1.22 (95% CI=1.10-1.25) times more likely to include CT compared to females, while there were no differences by sex for MRI or among inpatient stays. Urban residents, as compared to rural, were less likely to get CT in outpatient settings (adjusted odds ratio [aOR]=0.55, 95% CI=0.53-0.57). Rural residents demonstrated a larger proportion of inpatient admissions that had a CT.

CONCLUSIONS

Despite recommendations to avoid routine use of neuroimaging for mTBI, neuroimaging remained common practice in 2019.

Validation of Pediatric Emergency Care Applied Research Network (PECARN) rule in children with minor head trauma

The Pediatric Emergency Care Applied Research Network (PECARN) rule is commonly used for predicting the need for computed tomography (CT) scans in children with mild head trauma. The objective of this study was to validate the PECARN rule in Korean children presenting to the pediatric emergency department (PED) with head trauma. This study was a multicenter, retrospective, observational cohort study in two teaching PEDs in Korea between August 2015 and August 2016. In this observational study, 448 patients who visited PEDs were included in the final analysis. Risk stratification was performed with clinical decision support software based on the PECARN rule, and decisions to perform CT scans were subsequently made. Patients were followed-up by phone call between 7 days and 90 days after discharge from the PED. The sensitivity and specificity were analyzed. The sensitivity was 100% for all age groups, and no cases of clinically important traumatic brain injury (ciTBI) were identified in the very-low-risk group. CT scans were performed for 14.7% of patients in this study and for 33.8% in the original PECARN study. The PECARN rule successfully identified low-risk patients, and no cases of ciTBI were missed despite the reduced proportion of patients undergoing CT scans.

Effectiveness of Clinical Decision Support Systems on the Appropriate Use of Imaging for Central Nervous System Injuries: A Systematic Review

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.