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

Soltana, Kahina; Moore, Lynne; Bouderba, Samy; Lauzier, François; Clément, Julien; Mercier, Éric; Krouchev, Radoslav; Tardif, Pier‐Alexandre; Belcaïd, Amina; Stelfox, Thomas; Lamontagne, François; Archambault, Patrick; Turgeon, Alexis F.

doi:10.1016/j.jval.2021.06.008

Cited by 10 publications

(10 citation statements)

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“…38 Although we did not limit ourselves to this approach because guidelines largely focus on increasing the use of recommended practices, in our scoping review, we did scan the guidelines of relevant internationally recognized health care organizations to identify recommendations on trauma care practices that should be avoided. 10,30 These included 5 recommendations of the Choosing Wisely initiative, [11][12][13][14][15] of which 4 (80%) were selected in our study: initial head, cervical spine and ankle radiography in low-risk patients, and blood product transfusion. Whole-body CT in minor or single-system trauma was selected by the local stakeholder panel but not the international panel.…”

Section: Discussionmentioning

confidence: 99%

“…[31][32][33] We then estimated the frequency of practices that could be evaluated using trauma registry data from a Canadian provincial trauma system. 10…”

Section: Methodsmentioning

confidence: 99%

“…36 The questionnaire included a standardized information sheet on each practice with the following information: working definition, example of clinical presentation, synthesis of the best available evidence on effectiveness and harm, and estimates of frequency (eMethods 2 in Supplement 1). 10…”

Section: Questionnaire Developmentmentioning

confidence: 99%

“…However, we have already developed metrics for 9 of 16 selected indicators using trauma registry data. 10 Others may be operationalized by adding fields to trauma registries, linking registry data to other databases or using electronic medical records, where available. Indicators that cannot be measured with available data still have value as recommendations.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

“…Owing to its time-dependent nature, the multiple clinical specialties involved, and the multitude of diagnostic and treatment options, trauma care represents a fertile breeding ground for low-value care. Several specialty societies publish guidelines on evidence-based trauma care, but the emphasis is on adherence to recommended practices rather than practices that should be avoided . Furthermore, although the Choosing Wisely campaign publishes recommendations on practices to be questioned, few apply to trauma care .…”

Section: Introductionmentioning

confidence: 99%

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Quality Indicators Targeting Low-Value Clinical Practices in Trauma Care

et al. 2022

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for the Low-Value Practices in Trauma Care Expert Consensus Group IMPORTANCE The use of quality indicators has been shown to improve injury care processes and outcomes. However, trauma quality indicators proposed to date exclusively target the underuse of recommended practices. Initiatives such as Choosing Wisely publish lists of practices to be questioned, but few apply to trauma care, and most have not successfully been translated to quality indicators. OBJECTIVE To develop a set of evidence and patient-informed, consensus-based quality indicators targeting reductions in low-value clinical practices in acute, in-hospital trauma care.DESIGN, SETTING, AND PARTICIPANTS This 2-round Research and Development/University of California at Los Angeles (RAND/UCLA) consensus study, conducted from April 20 to June 9, 2021, comprised an online questionnaire and a virtual workshop led by 2 independent moderators. Two panels of international experts from Canada, Australia, the US, and the UK, and local stakeholders from Québec, Canada, represented key clinical expertise involved in trauma care and included 3 patient partners. MAIN OUTCOMES AND MEASURESPanelists were asked to rate 50 practices on a 7-point Likert scale according to 4 quality indicator criteria: importance, supporting evidence, actionability, and measurability. RESULTSOf 49 eligible experts approached, 46 (94%; 18 experts [39%] aged Ն50 years; 37 men [80%]) completed at least 1 round and 36 (73%) completed both rounds. Eleven quality indicators were selected overall, 2 more were selected by the international panel and a further 3 by the local stakeholder panel. Selected indicators targeted low-value clinical practices in the following aspects of trauma care: (1) initial diagnostic imaging (head, cervical spine, ankle, and pelvis), (2) repeated diagnostic imaging (posttransfer computed tomography [CT] and repeated head CT), (3) consultation (neurosurgical and spine), ( 4) surgery (penetrating neck injury), (5) blood product administration, (6) medication (antibiotic prophylaxis and late seizure prophylaxis), (7) trauma service admission (blunt abdominal trauma), (8) intensive care unit admission (mild complicated traumatic brain injury), and ( 9) routine blood work (minor orthopedic surgery). CONCLUSIONS AND RELEVANCEIn this consensus study, a set of consensus-based quality indicators were developed that were informed by the best available evidence and patient priorities, targeting low-value trauma care. Selected indicators represented a trauma-specific list of practices, the use of which should be questioned. Trauma quality programs in high-income countries may use these study results as a basis to select context-specific quality indicators to measure and reduce low-value care.

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Section: Discussionmentioning

confidence: 99%

“…[31][32][33] We then estimated the frequency of practices that could be evaluated using trauma registry data from a Canadian provincial trauma system. 10…”

Section: Methodsmentioning

confidence: 99%

Section: Questionnaire Developmentmentioning

confidence: 99%

Section: Strengths and Limitationsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Quality Indicators Targeting Low-Value Clinical Practices in Trauma Care

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Feasibility and diagnostic accuracy of fast whole-body MRI in slightly to moderately injured trauma patients

Reichel,

Hahlbohm,

Kromrey

et al. 2024

Eur Radiol

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Objectives To determine the feasibility and diagnostic accuracy of fast whole-body magnetic resonance imaging (WB-MRI) compared to whole-body computed tomography (WB-CT) in detecting injuries of slightly to moderately injured trauma patients. Materials and methods In a prospective single-center approach, trauma patients from convenience sampling with an expected Abbreviated Injury Scale (AIS) score ≤ 3 at admission, received an indicated contrast-enhanced WB-CT (reference standard) and a plain WB-MRI (index test) voluntarily up to five days after trauma. Two radiologists, blinded to the WB-CT findings, evaluated the absence or presence of injuries with WB-MRI in four body regions: head, torso, axial skeleton, and upper extremity. Diagnostic accuracy was determined using sensitivity, specificity, positive predictive value, and negative predictive value by body region. Results Between June 2019 and July 2021, 40 patients were assessed for eligibility of whom 35 (median age (interquartile range): 50 (32.5) years; 26 men) received WB-MRI. Of 140 body regions (35 patients × 4 regions), 31 true positive, 6 false positive, 94 true negative, and 9 false negative findings were documented with WB-MRI. Thus, plain WB-MRI achieved a total sensitivity of 77.5% (95%-confidence interval (CI): (61.6–89.2%)), specificity of 94% (95%-CI: (87.4–97.8%)), and diagnostic accuracy of 89.3% (95%-CI: (82.9–93.9%)). Across the four regions sensitivity and specificity varied: head (66.7%/93.1%), torso (62.5%/96.3%), axial skeleton (91.3%/75%), upper extremity (33.3%/100%). Both radiologists showed substantial agreement on the WB-MRI reading (Cohen’s Kappa: 0.66, 95%-CI: (0.51–0.81)). Conclusion Regarding injury detection, WB-MRI is feasible in slightly to moderately injured trauma patients, especially in the axial skeleton. Clinical relevance statement Besides offering a radiation-free approach, whole-body MRI detects injuries almost identically to whole-body CT in slightly to moderately injured trauma patients, who comprise a relevant share of all trauma patients. Key Points Whole-body MRI could offer radiation-free injury detection in slightly to moderately injured trauma patients. Whole-body MRI detected injuries almost identically compared to whole-body CT in this population. Whole-body MRI could be a radiation-free approach for slightly to moderately injured young trauma patients.

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Diagnostic utility of whole-body computed tomography/pan-scan in trauma: a systematic review and meta-analysis study

Fathi,

Mirjafari,

Yaghoobpoor

et al. 2024

Emerg Radiol

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Trauma is a significant cause of mortality and morbidity. It is crucial to diagnose trauma patients quickly to provide effective treatment interventions in such conditions. Whole-body computed tomography (WBCT)/pan-scan is an imaging technique that enables a faster and more efficient diagnosis for polytrauma patients. The purpose of this systematic review and meta-analysis is to evaluate the efficacy of WBCT in diagnosing injuries in polytrauma patients. We will also assess its impact on the mortality rate and length of hospital stay among trauma centers between patients who underwent WBCT and those who did not (non-WBCT). Twenty-seven studies meeting our inclusion criteria were selected among PubMed, Scopus, Web of Science, and Google Scholar. The criteria were centered on the significance of WBCT/pan-scan application in trauma patients. Stata version 15 was used to perform statistical analysis on the data. The authors have also used I2 statistics to evaluate heterogeneity. Egger and Begg’s tests were performed to rule out any publication bias. Total of twenty-seven studies including 68,838 trauma patients with a mean age of 45.0 ± 24.7 years were selected. Motor vehicle collisions were the most common cause of blunt injuries (80.0%). Head, neck, and face injuries were diagnosed in 44% (95% CI, 0.28–0.60; I2 = 99.8%), 6% (95% CI, 0.02–0.09; I2 = 97.2%), and 9% (95% CI, 0.05–0.13; I2 = 97.1%), respectively. Chest injuries were diagnosed by WBCT in 39% (95% CI, 0.28–0.51; I2 = 99.8%), abdominal injuries in 23% (95% CI, 0.03–0.43; I2 = 99.9%) of cases, spinal injuries 19% (95% CI, 0.11–0.27; I2 = 99.4%), extremity injuries 33% (95% CI, 0.23–0.43; I2 = 99.2%), and pelvic injuries 11% (95% CI, 0.04–0.18; I2 = 97.4%). A mortality odd ratio of 0.94 (95% CI, 0.83–1.06; I2 = 40.1%) was calculated while comparing WBCT and non-WBCT groups. This systematic review and meta-analysis provide insight into the possible safety, efficacy, and efficiency of WBCT/pan-scan as a diagnostic tool for trauma patients with serious injuries, regardless of their hemodynamic status. In patients with serious injuries from trauma, whether or not there are indicators of hemodynamic instability, our recommended approach is to, wherever possible, perform a WBCT without stopping the hemostatic resuscitation. By using this technology, the optimal surgical strategy for these patients can be decided upon without causing any delays in their final care or greatly raising their radiation dose.

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

Cited by 10 publications

References 38 publications

Quality Indicators Targeting Low-Value Clinical Practices in Trauma Care

Quality Indicators Targeting Low-Value Clinical Practices in Trauma Care

Feasibility and diagnostic accuracy of fast whole-body MRI in slightly to moderately injured trauma patients

Diagnostic utility of whole-body computed tomography/pan-scan in trauma: a systematic review and meta-analysis study

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