G Model
JINJ-5743; No. of Pages 6 Injury, Int. J. Care Injured xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Survey of patient and physician influences and decision-making regarding CT utilization for minor head injury§ Joshua Quaas a,*, Bruce Derrick b, Lindsey Mitrani a, Simon Baarbe a, Brett Yarusi a, Dan Wiener a, David Newman c a
Department of Emergency Medicine, St. Luke’s-Roosevelt Hospital, New York, NY, United States Department of Emergency Medicine, Duke University Medical Center, Durham, NC, United States c Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY, United States b
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 11 May 2014
Objective: Assess factors that influence both the patient and the physician in the setting of minor head injury in adults and the decision-making process around CT utilization. Methods: This is a convenience sample survey study of adult minor head injury patients (GCS 15) and their physicians regarding factors influencing the decision to use CT to evaluate for intra-cranial haemorrhage. Once a head CT was ordered and before the results were known, both the patient and physician were given a one-page survey asking questions about their concern for injury and rationale for CT use. CT results and surveys were then recorded in a centralized database and analyzed. Results: 584 subjects were enrolled over the 27-month study period. The rate of any intra-cranial haemorrhage was 3.3%. Both the physicians (6% pre-test estimate) and the patients (22% pre-test estimate) over-estimated risk for haemorrhage. Clinical decision rules were not met in 46% of cases where CT was used. Physicians listed an average of 5 factors from a list of 9 that influenced their decision to order CT. Patients listed an average of 1.7 factors influencing their decision to present to the Emergency Department for evaluation. Many patients felt cost (45%) and low risk stratification (34%) should weigh heavily in the decision to use CT. If asked to limit CT utilization, physicians were able to identify a group with less than 2% risk of injury. Conclusions: Patients with low risk of intra-cranial injury continue to be evaluated by CT. Physician decision-making around the use of CT to evaluate minor head injury is multi-factorial. Shared decisionmaking between the patient and the physician in a low risk minor head injury encounter shows promise as a method to reduce CT utilization in this low risk cohort. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Minor head injury CAT scan (computed tomography) Radiographic utilization Risk assessment Shared decision-making
Introduction Computed tomography (CT) rapidly identifies intracranial injury in the setting of head injury, as well as those in need of emergent neurosurgical management. The negative predictive value of a normal head CT approaches 100%, obviating the need for further medical observation in the vast majority of uncomplicated head-injured patients. This invaluable tool is
§ Meetings: Preliminary data from this study were presented at the ACEP national conference in 2011 with the title: Head CT Utilization for Minor Head Injury: What Motivates Patients to Present to the Emergency Department for Evaluation, and Why Do Emergency Physicians Choose to Evaluate Them With CT? Ann Emerg Med 2011;58(4):S248. * Corresponding author. Tel.: +1 212 523 3981; fax: +1 212 523 2186. E-mail addresses: [email protected], [email protected] (J. Quaas).
the current staple for emergency trauma care. Given the potential morbidity and mortality due to expanding intracranial haemorrhage (ICH), rates of CT utilization are rapidly increasing [1]. A large database review showed an overall 200% increase in the use of advanced imaging for trauma. Over-utilization could be suggested due to the lack of significant increase in the identification or incidence of life-threatening conditions [2]. The majority of patients with minor head injury have negative CT scans, a recent systematic review found a mean rate of 7.2% [3]. Several high quality clinical decision rules (CDR’s) help delineate which patient needs CT imaging, most notably the New Orleans Criteria (NOC) [4], Canadian Head CT Rule (CCHR) [5,6], and Nexus-II [7]. The rules have been externally validated with 100% sensitivity [8], near 100% sensitivity [9], and less than 95% sensitivity [10]. This variability causes some practitioners to be hesitant in relying on them, and
http://dx.doi.org/10.1016/j.injury.2014.05.012 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Quaas J, et al. Survey of patient and physician influences and decision-making regarding CT utilization for minor head injury. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.05.012
G Model
JINJ-5743; No. of Pages 6 J. Quaas et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
2
multiple reports show that physicians often ignore these CDR’s in clinical practice [11–14]. Minor head injury is a fairly heterogeneous group that can be classified via the Head Injury Severity Scale (HISS) as either minimal (Glasgow Coma Scale (GCS) of 15 and no loss of consciousness or amnesia), mild (GCS 14 or GCS 15 plus amnesia, loss of consciousness, or impaired alertness), or moderate (GCS 9-13, loss of consciousness >5 min, or focal neurologic deficit) [15]. Both the NOC and CCHR rules were developed in the setting of mild head injury and their generalizability to the minimal head injury patient is unclear. While the CDR’s are no doubt helpful, they are imperfect, with occasionally documented missed cases, and generally poor specificity (31–51%) [9]. Physicians and patients have expressed little tolerance for missing this potentially life-threatening pathology, which may be at the crux of rising CT use. Other factors may contribute to increasing utilization as well. This study aimed to learn more about patient rationale for presenting to the ED and the physician’s rationale and decision-making as it relates to CT utilization in the setting of minor head injury. Methods This is an Institutional Review Board-approved, prospective observational study. A convenience sample of adult subjects presenting to the emergency department with Minor Head Injury (MHI) between October 01, 2010, and December 31, 2012 were enrolled. The study was conducted at a two-site urban teaching hospital with a combined census of more than 150,000 patients per year. Trained research assistants identified and enrolled subjects between the hours of 8:00 AM and midnight by scanning ED computer tracking software for all subjects with non-contrast head CT’s ordered. Research assistants approached physicians to determine their patients’ eligibility for the study. The IRB approved a waiver of written consent as no patient-identifying information was recorded. Eligible subjects consented for the study by their willingness to complete the survey form in English or Spanish. These 2 languages constitute the vast majority of our ED patient population. The survey instrument (addendum 1) used for the physician was a single page, which consisted of 3 items filled in by the research associate and 10 questions for the treating physician. The patient survey was a single page that consisted of 7 questions followed by 3 demographic queries. The survey was conceived by the study authors. The survey specifically asks the physicians about use of the NOC and CCHR in their decision-making. NEXUS-II was not included as it has been rarely used historically in our ED. All subjects with head injury who had a GCS of 15 in the Emergency Department and a head CT order pending were eligible for this study. Exclusion criteria included (1) any neurologic deficit, (2) GCS < 15, (3) non-English or non-Spanish speaking, (4) age
JINJ-5743; No. of Pages 6 Injury, Int. J. Care Injured xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Survey of patient and physician influences and decision-making regarding CT utilization for minor head injury§ Joshua Quaas a,*, Bruce Derrick b, Lindsey Mitrani a, Simon Baarbe a, Brett Yarusi a, Dan Wiener a, David Newman c a
Department of Emergency Medicine, St. Luke’s-Roosevelt Hospital, New York, NY, United States Department of Emergency Medicine, Duke University Medical Center, Durham, NC, United States c Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY, United States b
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 11 May 2014
Objective: Assess factors that influence both the patient and the physician in the setting of minor head injury in adults and the decision-making process around CT utilization. Methods: This is a convenience sample survey study of adult minor head injury patients (GCS 15) and their physicians regarding factors influencing the decision to use CT to evaluate for intra-cranial haemorrhage. Once a head CT was ordered and before the results were known, both the patient and physician were given a one-page survey asking questions about their concern for injury and rationale for CT use. CT results and surveys were then recorded in a centralized database and analyzed. Results: 584 subjects were enrolled over the 27-month study period. The rate of any intra-cranial haemorrhage was 3.3%. Both the physicians (6% pre-test estimate) and the patients (22% pre-test estimate) over-estimated risk for haemorrhage. Clinical decision rules were not met in 46% of cases where CT was used. Physicians listed an average of 5 factors from a list of 9 that influenced their decision to order CT. Patients listed an average of 1.7 factors influencing their decision to present to the Emergency Department for evaluation. Many patients felt cost (45%) and low risk stratification (34%) should weigh heavily in the decision to use CT. If asked to limit CT utilization, physicians were able to identify a group with less than 2% risk of injury. Conclusions: Patients with low risk of intra-cranial injury continue to be evaluated by CT. Physician decision-making around the use of CT to evaluate minor head injury is multi-factorial. Shared decisionmaking between the patient and the physician in a low risk minor head injury encounter shows promise as a method to reduce CT utilization in this low risk cohort. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Minor head injury CAT scan (computed tomography) Radiographic utilization Risk assessment Shared decision-making
Introduction Computed tomography (CT) rapidly identifies intracranial injury in the setting of head injury, as well as those in need of emergent neurosurgical management. The negative predictive value of a normal head CT approaches 100%, obviating the need for further medical observation in the vast majority of uncomplicated head-injured patients. This invaluable tool is
§ Meetings: Preliminary data from this study were presented at the ACEP national conference in 2011 with the title: Head CT Utilization for Minor Head Injury: What Motivates Patients to Present to the Emergency Department for Evaluation, and Why Do Emergency Physicians Choose to Evaluate Them With CT? Ann Emerg Med 2011;58(4):S248. * Corresponding author. Tel.: +1 212 523 3981; fax: +1 212 523 2186. E-mail addresses: [email protected], [email protected] (J. Quaas).
the current staple for emergency trauma care. Given the potential morbidity and mortality due to expanding intracranial haemorrhage (ICH), rates of CT utilization are rapidly increasing [1]. A large database review showed an overall 200% increase in the use of advanced imaging for trauma. Over-utilization could be suggested due to the lack of significant increase in the identification or incidence of life-threatening conditions [2]. The majority of patients with minor head injury have negative CT scans, a recent systematic review found a mean rate of 7.2% [3]. Several high quality clinical decision rules (CDR’s) help delineate which patient needs CT imaging, most notably the New Orleans Criteria (NOC) [4], Canadian Head CT Rule (CCHR) [5,6], and Nexus-II [7]. The rules have been externally validated with 100% sensitivity [8], near 100% sensitivity [9], and less than 95% sensitivity [10]. This variability causes some practitioners to be hesitant in relying on them, and
http://dx.doi.org/10.1016/j.injury.2014.05.012 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Quaas J, et al. Survey of patient and physician influences and decision-making regarding CT utilization for minor head injury. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.05.012
G Model
JINJ-5743; No. of Pages 6 J. Quaas et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
2
multiple reports show that physicians often ignore these CDR’s in clinical practice [11–14]. Minor head injury is a fairly heterogeneous group that can be classified via the Head Injury Severity Scale (HISS) as either minimal (Glasgow Coma Scale (GCS) of 15 and no loss of consciousness or amnesia), mild (GCS 14 or GCS 15 plus amnesia, loss of consciousness, or impaired alertness), or moderate (GCS 9-13, loss of consciousness >5 min, or focal neurologic deficit) [15]. Both the NOC and CCHR rules were developed in the setting of mild head injury and their generalizability to the minimal head injury patient is unclear. While the CDR’s are no doubt helpful, they are imperfect, with occasionally documented missed cases, and generally poor specificity (31–51%) [9]. Physicians and patients have expressed little tolerance for missing this potentially life-threatening pathology, which may be at the crux of rising CT use. Other factors may contribute to increasing utilization as well. This study aimed to learn more about patient rationale for presenting to the ED and the physician’s rationale and decision-making as it relates to CT utilization in the setting of minor head injury. Methods This is an Institutional Review Board-approved, prospective observational study. A convenience sample of adult subjects presenting to the emergency department with Minor Head Injury (MHI) between October 01, 2010, and December 31, 2012 were enrolled. The study was conducted at a two-site urban teaching hospital with a combined census of more than 150,000 patients per year. Trained research assistants identified and enrolled subjects between the hours of 8:00 AM and midnight by scanning ED computer tracking software for all subjects with non-contrast head CT’s ordered. Research assistants approached physicians to determine their patients’ eligibility for the study. The IRB approved a waiver of written consent as no patient-identifying information was recorded. Eligible subjects consented for the study by their willingness to complete the survey form in English or Spanish. These 2 languages constitute the vast majority of our ED patient population. The survey instrument (addendum 1) used for the physician was a single page, which consisted of 3 items filled in by the research associate and 10 questions for the treating physician. The patient survey was a single page that consisted of 7 questions followed by 3 demographic queries. The survey was conceived by the study authors. The survey specifically asks the physicians about use of the NOC and CCHR in their decision-making. NEXUS-II was not included as it has been rarely used historically in our ED. All subjects with head injury who had a GCS of 15 in the Emergency Department and a head CT order pending were eligible for this study. Exclusion criteria included (1) any neurologic deficit, (2) GCS < 15, (3) non-English or non-Spanish speaking, (4) age
