A Cost-Effectiveness Analysis Comparing Clinical Decision Rules PECARN, CATCH, and CHALICE With Usual Care for the Management of Pediatric Head Injury

Quality of health economic evaluations in emergency medicine journals: a systematic review

OBJECTIVE

Health economic evaluations are used in decision-making regarding resource allocation and it is imperative that they are completed with rigor. The primary objectives were to describe the characteristics and assess the quality of economic evaluations published in emergency medicine journals.

METHODS

Two reviewers independently searched 19 emergency medicine-specific journals via Medline and Embase from inception until March 3, 2022. Quality assessment was completed using the Quality of Health Economic Studies (QHES) tool, and the primary outcome was the QHES score out of 100. Additionally, we identified factors that may contribute to higher-quality publications.

RESULTS

7260 unique articles yielded 48 economic evaluations that met inclusion criteria. Most studies were cost-utility analyses and of high quality, with a median QHES score of 84 (interquartile range, IQR: 72, 90). Studies based on mathematical models and those primarily designed as an economic evaluation were associated with higher quality scores. The most commonly missed QHES items were: (i) providing and justifying the perspective of the analysis, (ii) providing justification for the primary outcome, and (iii) selecting an outcome that was long enough to allow for relevant events to occur.

CONCLUSIONS

The majority of health economic evaluations in the emergency medicine literature are cost-utility analyses and are of high quality. Decision analytic models and studies primarily designed as economic analyses were positively correlated with higher quality. To improve study quality, future EM economic evaluations should justify the choice of the perspective of the analysis and the selection of the primary outcome.

Cost-effectiveness of patient observation on cranial CT use with minor head trauma

OBJECTIVE

To evaluate the cost-effectiveness of planned observation on cranial CT use in children with minor head trauma.

DESIGN

Planned secondary analysis of a multicentre prospective observation study.

SETTING

Australia and New Zealand.

PATIENTS

An analytic cohort of 18 471 children aged <18 years with Glasgow Coma Scale scores 14-15 presenting <24 hours after blunt head trauma stratified by the Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) risk categories.

INTERVENTION

A plan for observation and immediate CT scan were documented after the initial assessment. The planned observation group included those with planned observation and no immediate plan for CT.

MAIN OUTCOME MEASURES

Taking an Australian public-funded healthcare perspective, we estimated the cost-effectiveness of planned observation on the adjusted mean costs per child and CT use reduction by net benefit regression analysis using ordinary least squares with robust SEs and bootstrapping. All costs presented in 2018 euros.

RESULTS

Planned observation in 4945 (27%) children was cost-saving of €85 (95% CI -120 to -51) with 10.4% lower CT use (95% CI 9.6 to 11.2). This strategy was cost-saving for the PECARN high-risk (-€757 (95% CI -961 to -554)) and intermediate-risk (-€52 (95% CI -99 to -4.3)) categories, with 43% (95% CI 39 to 47) and 11% (95% CI 9.6 to 12.4) lower CT use, respectively. The very low-risk category incurred more cost of €86 (95% CI 67 to 104) with planned observation and 0.05% lower CT use (95% CI -0.61 to 0.71).

CONCLUSION

Planned ED observation in selected children with minor head trauma is cost-effective for reducing CT use for the PECARN intermediate-risk and high-risk categories.

TRIAL REGISTRATION NUMBER

ACTRN12614000463673.

Economic Evaluation of In-Hospital Clinical Practices in Acute Injury Care: A Systematic Review

OBJECTIVES

Underuse of high-value clinical practices and overuse of low-value practices are major sources of inefficiencies in modern healthcare systems. To achieve value-based care, guidelines and recommendations should target both underuse and overuse and be supported by evidence from economic evaluations. We aimed to conduct a systematic review of the economic value of in-hospital clinical practices in acute injury care to advance knowledge on value-based care in this patient population.

METHODS

Pairs of independent reviewers systematically searched MEDLINE, Embase, Web of Science, and Cochrane Central Register for full economic evaluations of in-hospital clinical practices in acute trauma care published from 2009 to 2019 (last updated on June 17, 2020). Results were converted into incremental net monetary benefit and were summarized with forest plots. The protocol was registered with PROSPERO (CRD42020164494).

RESULTS

Of 33 910 unique citations, 75 studies met our inclusion criteria. We identified 62 cost-utility, 8 cost-effectiveness, and 5 cost-minimization studies. Values of incremental net monetary benefit ranged from international dollars -467 000 to international dollars 194 000. Of 114 clinical interventions evaluated (vs comparators), 56 were cost-effective. We identified 15 cost-effective interventions in emergency medicine, 6 in critical care medicine, and 35 in orthopedic medicine. A total of 58 studies were classified as high quality and 17 as moderate quality. From studies with a high level of evidence (randomized controlled trials), 4 interventions were clearly dominant and 8 were dominated.

CONCLUSIONS

This research advances knowledge on value-based care for injury admissions. Results suggest that almost half of clinical interventions in acute injury care that have been studied may not be cost-effective.

Trends of paediatric head injury and acute care costs in Australia

AIM

Paediatric head injuries (PHI) are the most common cause of trauma-related emergency department (ED) presentations. This study sought to report the incidence of PHI in Australia, examine the temporal trends from 2014 to 2018 and estimate the patient and population-level acute care costs.

METHODS

Taking a public-sector health-care perspective, we applied direct and indirect hospital costs for PHI-related ED visits and acute admissions. All costs were inflated to 2018 Australian dollars ($). The patient-level analysis was performed with data from 17 841 children <18 years old enrolled in the prospective Australasian Paediatric Head Injury Study. Mechanisms of injury were characterised by the total and average acute care costs. The population-level data of PHI-related ED presentations were obtained from the Independent Hospital Pricing Authority. Age-standardised incidence rates (IR) and incidence rate ratios (IRR) were calculated, and negative binomial regression examined the temporal trend.

RESULTS

The age-standardised IR for PHI was 2734 per 100 000 population in 2018, with a significant increase over 5 years (IRR 1.13, 95% confidence interval (CI) 1.12-1.14; P < 0.001) and acute care costs of $154 million. Falls occurred in 70% of the study cohort, with average costs per episode of $666 (95% CI: $627-$706), accounting for 47% of acute care costs. Transportation-related injuries occurred in 4.1% of the study cohort, with average costs per episode of $8555 (95% CI: $6193-$10 917), accounting for 35% of acute care costs.

CONCLUSION

PHI have increased significantly in Australia and are associated with substantial acute care costs. Population-based efforts are required for road safety and injury prevention.

ACR Appropriateness Criteria® Head Trauma: 2021 Update

Head trauma (ie, head injury) is a significant public health concern and is a leading cause of morbidity and mortality in children and young adults. Neuroimaging plays an important role in the management of head and brain injury, which can be separated into acute (0-7 days), subacute (<3 months), then chronic (>3 months) phases. Over 75% of acute head trauma is classified as mild, of which over 75% have a normal Glasgow Coma Scale score of 15, therefore clinical practice guidelines universally recommend selective CT scanning in this patient population, which is often based on clinical decision rules. While CT is considered the first-line imaging modality for suspected intracranial injury, MRI is useful when there are persistent neurologic deficits that remain unexplained after CT, especially in the subacute or chronic phase. Regardless of time frame, head trauma with suspected vascular injury or suspected cerebrospinal fluid leak should also be evaluated with CT angiography or thin-section CT imaging of the skull base, respectively. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Pediatric minor head trauma in Brazil and external validation of PECARN rules with a cost-effectiveness analysis

BACKGROUND

Pediatric minor head trauma approaches aim to ensure the absence of traumatic brain lesions, minimize ionizing radiation, and enhance cost control. We evaluated the applicability and cost-effectiveness of the Pediatric Emergency Care Applied Research Network (PECARN) rules after head trauma and rationalize the use of head computed tomography (CT) scans.

METHODS

We retrospectively divided patients <18 years old who presented at a single institution in Brazil with minor head trauma into four groups: Group I (skull X-ray only), Group II (head CT only), Group III (X-ray and CT), and Group IV (observation only). Direct costs were calculated based on examination and length of hospitalization. The PECARN rules were applied retrospectively in each patient to determine who required a CT scan, and the costs were re-calculated.

RESULTS

Of the 1328 patients, CT scans were performed in 36.4% and X-rays in 52.6%. The mean cost was USD 5.88, 34.58, 41.85, and 4.04 for Groups I-IV, respectively. After applying the PECARN rules, 77.6% of patients no longer required a CT scan, and overall costs were reduced from USD 16.71 to 7.88 (p < .001). Conclusion: The PECARN rules demonstrated a meaningful cost-effectiveness and should be applied to the Brazilian pediatric population.

Establishing a research network

Multicentre research provides advantages over single-centre research by maximising available patient numbers while pooling varied expertise and resources available across different participating investigators and sites. The increased complexity of multicentre regulatory approvals, communication and study management, can be mitigated by the formation of a research network where multicentre efforts move from ad hoc, single projects to formalised ongoing collaboration. Network research helps prioritise research efforts and importantly fosters the development of a collaborative track record in terms of research expertise, research capacity and grant success. It also has the potential to rapidly change patient care across many hospitals as research results will be more generalizable and definitive. This paper sets out the key elements of network research, its benefits and possible challenges drawing on the example of PREDICT (Paediatric Research in Emergency Departments International Collaborative) an established paediatric emergency research network in Australia and New Zealand.

Application of PECARN rules would significantly decrease CT rates in a Dutch cohort of children with minor traumatic head injuries

The aim of this study was to determine the potential impact of the Pediatric Emergency Care Applied Research Network (PECARN) rules on the CT rate in a large paediatric minor traumatic head injury (MTHI) cohort and compare this with current national Dutch guidelines. This was a planned sub-study of a prospective multicentre observational study that enrolled 1006 children younger than 18 years with MTHI. We calculated the number of recommended CT scans and described trauma-related CT scan abnormalities. The PECARN rules recommended a significantly lower percentage of CT scans in all age categories, namely 101/357 (28.3%) versus 164/357 (45.9%) (p < 0.001) in patients under 2 years of age and 148/623 (23.8%) versus 394/623 (63.2%) (p < 0,001) versus in patients 2 years and older.Conclusion: The projected CT rate can significantly be reduced if the PECARN rules are applied. We therefore advocate that the PECARN guidelines are also implemented in The Netherlands. What is Known: • To guide clinicians whether to perform a CT scan in children with a minor traumatic head injury (MTHI) clinical decision rules has been developed. • The overall CT scan rate in adherence with the Dutch MTHI guidelines is 44%. What is New: • The projected CT rate can significantly be reduced in a Dutch cohort of MTHI if the PECARN rules are applied. • The Dutch national guidelines for MTHI can safely be replaced by the PECARN rules.

Children With Minor Blunt Head Trauma Presenting to the Emergency Department

In our state-of-the-art review, we summarize the best-available evidence for the optimal emergency department management of children with minor blunt head trauma. Minor blunt head trauma in children is a common reason for emergency department evaluation, although clinically important traumatic brain injuries (TBIs) as a result are uncommon. Cranial computed tomography (CT) scanning is the reference standard for the diagnosis of TBIs, although they should be used judiciously because of the risk of lethal malignancy from ionizing radiation exposure, with the greatest risk to the youngest children. Available TBI prediction rules can assist with CT decision-making by identifying patients at either low risk for TBI, for whom CT scans may safely be obviated, or at high risk, for whom CT scans may be indicated. For clinical prediction rules to change practice, however, they require active implementation. Observation before CT decision-making in selected patients may further reduce CT rates without missing children with clinically important TBIs. Future work is also needed to incorporate patient and family preferences into these decision-making algorithms when the course of action is not clear.

Multi-centre study found that strict adherence to guidelines led to computed tomography scans being overused in children with minor head injuries

AIM

Our primary aim was to calculate the head computed tomography (CT) scan rate in children with a minor head injury (MHI) when the Dutch National guidelines were followed in clinical practice. The secondary aim was to determine the incidence of CT abnormalities and the guideline predictors associated with traumatic abnormalities.

METHODS

We performed a multi-centre, prospective observational cross-sectional study in the emergency departments of six hospitals in The Netherlands between 1 April 2015 and 31 December 2016.

RESULTS

Data on 1002 patients were studied and 69% of cases complied with the guidelines. The overall CT rate was 44% and the incidence of traumatic abnormal CT findings was 13%. CT scans were performed in 19% of children under two years of age, 48% of children between two and five years and 63% of children aged six years or more. Multivariate regression analysis for all age categories showed that CT abnormalities were predicted by a Glasgow Coma Scale of less than 15, suspicion of a basal skull fracture, vomiting and scalp haematomas or external lesions of the skull.

CONCLUSION

Strict adherence to the Dutch national guidelines resulted in CT overuse. New guidelines are needed to safely reduce CT scan indications.

Review article: A primer for clinical researchers in the emergency department: Part X. Understanding economic evaluation alongside emergency medicine research

In this series we address research topics in emergency medicine. While traditionally there was an almost exclusive focus on the efficacy and effectiveness of interventions in emergency research, analysis of the costs and the societal impact of different approaches and pathways have become increasingly important. In this paper we will address what health economics means and discuss the different types and key features of economic evaluation relevant for clinical researchers.

Grading and assessment of clinical predictive tools for paediatric head injury: a new evidence-based approach

BACKGROUND

Many clinical predictive tools have been developed to diagnose traumatic brain injury among children and guide the use of computed tomography in the emergency department. It is not always feasible to compare tools due to the diversity of their development methodologies, clinical variables, target populations, and predictive performances. The objectives of this study are to grade and assess paediatric head injury predictive tools, using a new evidence-based approach, and to provide emergency clinicians with standardised objective information on predictive tools to support their search for and selection of effective tools.

METHODS

Paediatric head injury predictive tools were identified through a focused review of literature. Based on the critical appraisal of published evidence about predictive performance, usability, potential effect, and post-implementation impact, tools were evaluated using a new framework for grading and assessment of predictive tools (GRASP). A comprehensive analysis was conducted to explain why certain tools were more successful.

RESULTS

Fourteen tools were identified and evaluated. The highest-grade tool is PECARN; the only tool evaluated in post-implementation impact studies. PECARN and CHALICE were evaluated for their potential effect on healthcare, while the remaining 12 tools were only evaluated for predictive performance. Three tools; CATCH, NEXUS II, and Palchak, were externally validated. Three tools; Haydel, Atabaki, and Buchanich, were only internally validated. The remaining six tools; Da Dalt, Greenes, Klemetti, Quayle, Dietrich, and Güzel did not show sufficient internal validity for use in clinical practice.

CONCLUSIONS

The GRASP framework provides clinicians with a high-level, evidence-based, comprehensive, yet simple and feasible approach to grade, compare, and select effective predictive tools. Comparing the three main tools which were assigned the highest grades; PECARN, CHALICE and CATCH, to the remaining 11, we find that the quality of tools' development studies, the experience and credibility of their authors, and the support by well-funded research programs were correlated with the tools' evidence-based assigned grades, and were more influential, than the sole high predictive performance, on the wide acceptance and successful implementation of the tools. Tools' simplicity and feasibility, in terms of resources needed, technical requirements, and training, are also crucial factors for their success.