Variability of physicians’ thresholds for neuroimaging in children with recurrent headache

Abstract

BackgroundWe sought to determine the extent to which physicians agree about the appropriate decision threshold for recommending magnetic resonance imaging in a clinical practice guideline for children with recurrent headache.MethodsWe surveyed attending physicians in Canada practicing in community pediatrics, child neurology, pediatric radiology, and pediatric neurosurgery. For children in each of six risk categories, physicians were asked to determine whether they would recommend for or against routine magnetic resonance imaging of the brain in a clinical practice guideline for children with recurrent headache.ResultsCompleted surveys were returned by 114 physicians. The proportion recommending routine neuroimaging for each risk group was 100% (50% risk), 99% (10% risk), 93% (4% risk), 54% (1% risk), 25% (0.4% risk), 4% (0.01% risk). Community pediatricians, physicians in practice >15 years, and physicians who believed they ordered neuroimaging less often than peers were less likely to recommend neuroimaging for the 1% risk group (all p < 0.05).ConclusionsThere is no consensus among pediatric specialists regarding the appropriate decision threshold for neuroimaging in a clinical practice guideline for children with recurrent headache. Because of the impact that individual threshold preferences may have on guidelines, these findings support the need for careful composition of guideline committees and consideration of the role of patient and family preferences. Our findings also support the need for transparency in guidelines regarding how evidence was translated into recommendations and how conflicts were resolved.

Neuroimaging for Migraine: The American Headache Society Systematic Review and Evidence‐Based Guideline

“…52 In many cases, clinicians may overestimate the patient's desire to receive neuroimaging. 54 While some clinicians may request neuroimaging hoping to ease the anxiety of their patients, 55 the initial reduction in anxiety is lost at 1 year follow-up in a study of chronic daily headache. 54 While some clinicians may request neuroimaging hoping to ease the anxiety of their patients, 55 the initial reduction in anxiety is lost at 1 year follow-up in a study of chronic daily headache.…”

“…53 The threshold to perform neuroimaging varies considerably from provider to provider, even among specialists. 54 While some clinicians may request neuroimaging hoping to ease the anxiety of their patients, 55 the initial reduction in anxiety is lost at 1 year follow-up in a study of chronic daily headache. 56 However, neuroimaging significantly reduced costs for patients with high levels of psychiatric co-morbidity.…”

Physician Risk Perception and Testing Behaviors for Children With Fever

“…Understanding which management decisions are sensitive to clinician risk perception would facilitate promoting interventions to blunt the impact of individual differences in risk tolerance 21–23 . For instance, the development and adoption of clinical guidelines is one potential strategy of homogenizing care between clinicians 24,25 …”

“…[21][22][23] For instance, the development and adoption of clinical guidelines is one potential strategy of homogenizing care between clinicians. 24,25 Fever is the most common pediatric chief complaint in the emergency department (ED). 26 Parent and clinician fears about fever may drive testing decisions.…”