Mild head injury: observation or computed tomography? Economic aspects by literature review and decision analysis

Abstract

Objectives: To compare the costs of two strategies for acute management of mild head injury: inhospital observation compared with acute computed tomography (CT) and home care. Methods: Studies comparing costs for the two strategies that seem to have similar outcomes for patients were systematically reviewed. A decision tree analysis to compare the costs was also constructed, based on Swedish national costs and the risks found in a recent review on mild head injury complications. Results: No studies were found that directly measured and compared risks, benefits, and costs of the two strategies. In the four studies retrieved, involving 4126 patients, the costs for hospital observation were factual, but a model was used to evaluate costs for the CT strategy. On average, costs were one third lower with CT. Also, the decision tree analysis demonstrated that the CT strategy was one third less expensive than inhospital observation. A sensitivity analysis showed this to be valid for nearly all cases. If these calculations hold true, a change of strategy could result in annual savings of £280 000/million inhabitants. Conclusion: The CT strategy seems to cost one third less than hospital observation.M ild head injury is one of the most common reasons for hospital admission after trauma. Annually, 17 000 patients (190/100 000 inhabitants) are admitted with mild head injuries in Sweden.1 Direct costs for the acute management of mild head injury in Sweden are estimated to be £7.6 million annually, £84 000/100 000 inhabitants.2 The indirect costs could not be reliably estimated, but seem to be considerably higher than the direct costs.No uniform guidelines for the care of mild head injury are broadly accepted. Sweden and many other European countries have a longstanding tradition of managing mild head injury with inhospital observation.3-7 Some of the admitted patients receive a computed tomography (CT) scan in addition to inhospital care, around 20% in Sweden. 4 The question has been raised concerning whether all patients with mild head injury instead can be triaged for admission with an early CT scan.8 Unnecessary admissions of patients with normal CT findings might thereby be avoided, and better care provided for patients with abnormal CT findings and at higher risk for deterioration with need for surgery or more intensive care. In our recent review of complications from mild head injury we estimated that even with the CT strategy at least 8% of the patients will require inhospital care because of abnormal CT findings or complications.9 It is also possible that an additional 10% might require admission because of organisational, medical, or social reasons despite normal CT findings.The use of skull radiography to triage patients with mild head injury for admission or for CT has been discussed.10 11 In Sweden, this method is not used routinely. 4 Most evidence shows that skull radiography is less informative than CT and of limited value for the management of head injuries of a milder degree.12 13 Furthermore, skull radiogra...

Diagnostic management strategies for adults and children with minor head injury: a systematic review and an economic evaluation

“…34,35 Both cost analyses based upon randomised controlled trial (RCT) data 36 and economic modelling 37 suggest that a CT-based strategy is cheaper. However, admission-based strategies may be an inappropriate comparator for cost-effectiveness analyses because they appear to be expensive and of limited effectiveness, particularly if applied unselectively.…”

“…Of the titles and abstracts screened, 12 relevant full papers were retrieved and assessed in detail. 21,22,37,136,[152][153][154][155][156][157][158][159] One RCT 37 comparing immediate CT during triage with observation in hospital for patients with MHI fulfilled the inclusion criteria. A flow chart describing the process of identifying relevant literature can be found in Appendix 7.…”

Geriatric Traumatic Brain Injury in Hungary and Eastern Europe

“…Not surprisingly, current diagnostic and management protocols advise more liberal use of CT, particularly in the elderly population [19,22,23].…”

Utility of surveillance imaging after minor blunt head trauma

“…Methods of diagnosis, 4,11 hospital admission criteria, 1,15 identification of child abuse victims, 2,17 and return-to-play criteria 13,14 are just some of the active areas of research. Follow-up care of pediatric patients with minor head trauma, accompanied by surveillance imaging when appropriate, is rendered by primary physicians, neurosurgeons, and sports medicine programs among others.…”