Cost-effectiveness of immediate total-body CT in patients with severe trauma (REACT-2 trial)

BACKGROUND

The effect of immediate total-body CT (iTBCT) on health economic aspects in patients with severe trauma is an underreported issue. This study determined the cost-effectiveness of iTBCT compared with conventional radiological imaging with selective CT (standard work-up (STWU)) during the initial trauma evaluation.

METHODS

In this multicentre RCT, adult patients with a high suspicion of severe injury were randomized in-hospital to iTBCT or STWU. Hospital healthcare costs were determined for the first 6 months after the injury. The probability of iTBCT being cost-effective was calculated for various levels of willingness-to-pay per extra patient alive.

RESULTS

A total of 928 Dutch patients with complete clinical follow-up were included. Mean costs of hospital care were €25 809 (95 per cent bias-corrected and accelerated (bca) c.i. €22 617 to €29 137) for the iTBCT group and €26 155 (€23 050 to €29 344) for the STWU group, a difference per patient in favour of iTBCT of €346 (€4987 to €4328) (P = 0.876). Proportions of patients alive at 6 months were not different. The proportion of patients alive without serious morbidity was 61.6 per cent in the iTBCT group versus 66.7 per cent in the STWU group (difference -5.1 per cent; P = 0.104). The probability of iTBCT being cost-effective in keeping patients alive remained below 0.56 for the whole group, but was higher in patients with multiple trauma (0.8-0.9) and in those with traumatic brain injury (more than 0.9).

CONCLUSION

Economically, from a hospital healthcare provider perspective, iTBCT should be the diagnostic strategy of first choice in patients with multiple trauma or traumatic brain injury.

High rates of clinically relevant incidental findings by total-body CT scanning in trauma patients; results of the REACT-2 trial

Objectives

To determine whether there is a difference in frequency and clinical relevance of incidental findings detected by total-body computed tomography scanning (TBCT) compared to those by the standard work-up (STWU) with selective computed tomography (CT) scanning.

Methods

Trauma patients from five trauma centres were randomized between April 2011 and January 2014 to TBCT imaging or STWU consisting of conventional imaging with selective CT scanning. Incidental findings were divided into three categories: 1) major finding, may cause mortality; 2) moderate finding, may cause morbidity; and 3) minor finding, hardly relevant. Generalized estimating equations were applied to assess differences in incidental findings.

Results

In total, 1083 patients were enrolled, of which 541 patients (49.9 %) were randomized for TBCT and 542 patients (50.1 %) for STWU. Major findings were detected in 23 patients (4.3 %) in the TBCT group compared to 9 patients (1.7 %) in the STWU group (adjusted rate ratio 2.851; 95%CI 1.337–6.077; p < 0.007). Findings of moderate relevance were detected in 120 patients (22.2 %) in the TBCT group compared to 86 patients (15.9 %) in the STWU group (adjusted rate ratio 1.421; 95%CI 1.088–1.854; p < 0.010).

Conclusions

Compared to selective CT scanning, more patients with clinically relevant incidental findings can be expected by TBCT scanning.

Key points

• Total-body CT scanning in trauma results in 1.5 times more incidental findings.

• Evaluation by TBCT in trauma results in more patients with incidental findings.

• In every category of clinical relevance, TBCT detects more incidental findings.

Incidental findings on total-body CT scans in trauma patients

INTRODUCTION

Total-body Computed Tomography (CT) scans are increasingly used in trauma care. Herewith the observation of incidental findings, trauma unrelated findings, is also increased. The aim of this study was to evaluate the number of incidental findings in adult trauma patients.

PATIENTS AND METHODS

All consecutive trauma patients that underwent total-body CT scanning between January 2009 and December 2011 were analysed. Incidental findings were divided in three categories: category I (potentially severe condition, further diagnostic work-up is required), category II (diagnostic work-up dependent on patients' symptoms) and category III (findings of minor concern, no diagnostic work-up required).

RESULTS

There were 2248 trauma room presentations; 321 patients underwent a total-body CT scan (14.3%). In 143 patients (44.5%), 186 incidental findings were reported. There were 13 category I findings (7.0%), 45 category II findings (24.2%) and 128 category III incidental findings (68.8%). Overall, 18 patients (5.6%) required additional diagnostic work-up. Four patients underwent work-up by additional radiologic imaging. Three patients required further invasive work-up or treatment. Three patients were transferred to another hospital, no extended follow-up was performed. In three patients, there was no documentation of follow-up. Five patients deceased before diagnostic work-up of the incidental finding could start.

CONCLUSION

Total-body CT scanning as part of the evaluation of trauma patients leads to a substantial amount of incidental findings. Documentation of incidental findings and their clinical consequences was incomplete. Therefore, the findings of this study have prompted us to add an item to our electronic trauma room report that obliges residents to report whether or not incidental findings are found during trauma imaging.

Time to intervention in patients with splenic injury in a Dutch level 1 trauma centre

BACKGROUND

Timely intervention in patients with splenic injury is essential, since delay to treatment is associated with an increased risk of mortality. Transcatheter Arterial Embolisation (TAE) is increasingly used as an adjunct to non-operative management. The aim of this study was to report time intervals between admission to the trauma room and start of intervention (TAE or splenic surgery) in patients with splenic injury.

METHODS

Consecutive patients with splenic injury aged ≥ 16 years admitted between January 2006 and January 2012 were included. Data were reported according to haemodynamic status (stable versus unstable). In haemodynamically (HD) unstable patients, transfusion requirement, intervention-related complications and the need for a re-intervention were compared between the TAE and splenic surgery group.

RESULTS

The cohort consisted of 96 adults of whom 16 were HD unstable on admission. In HD stable patients, median time to intervention was 105 (IQR 77-188) min: 117 (IQR 78-233) min for TAE compared to 95 (IQR 69-188) for splenic surgery (p=0.58). In HD unstable patients, median time to intervention was 58 (IQR 41-99) min: 46 (IQR 27-107) min for TAE compared to 64 (IQR 45-80) min for splenic surgery (p=0.76). The median number of transfused packed red blood cells was 8 (3-22) in HD unstable patients treated with TAE versus 24 (9-55) in the surgery group (p=0.09). No intervention-related complications occurred in the TAE group and one in the splenic surgery group (p=0.88). Two spleen related re-interventions were performed in the TAE group versus 3 in the splenic surgery group (p=0.73).

CONCLUSIONS

Time to intervention did not differ significantly between HD unstable patients treated with TAE and patients treated with splenic surgery. Although no difference was observed with regard to intervention-related complications and the need for a re-intervention, a trend towards lower transfusion requirement was observed in patients treated with TAE compared to patients treated with splenic surgery. We conclude that if 24/7 interventional radiology facilities are available, TAE is not associated with time loss compared to splenic surgery, even in HD unstable patients.

Systematic review of flexion/extension radiography of the cervical spine in trauma patients

INTRODUCTION

The aim of this review was to investigate whether Flexion/Extension (F/E) radiography adds diagnostic value to CT or MRI in the detection of cervical spine ligamentous injury and/or clinically significant cervical spine instability of blunt trauma patients.

METHODS

A systematic search of literature was done in Pubmed, Embase and Cochrane Library databases. Primary outcome was sensitivity and specificity of F/E radiography. Secondary outcomes were the positive predicting value (PPV) and negative predicting value (NPV) (with CT or MRI as reference tests due to the heterogeneity of the included studies) of each modality and the quality of F/E radiography.

RESULTS

F/E radiography was overall regarded to be inferior to CT or MRI in the detection of ligamentous injury. This was reflected by the high specificity and NPV for CT with F/E as reference test (ranging from 97 to 100% and 99 to 100% respectively) and the ambiguous results for F/E radiography with MRI as its reference test (0-98% and 0-83% for specificity and NPV respectively). Image quality of F/E radiography was reported to have 31 to 70% adequacy, except in two studies which reported an adequacy of respectively 4 and 97%.

CONCLUSION

This systematic review of the literature shows that F/E radiography adds little diagnostic value to the evaluation of blunt trauma patients compared to CT and MRI, especially in those cases where CT or MRI show no indication of ligamentous injury.

Systematic review and meta-analysis of immediate total-body computed tomography compared with selective radiological imaging of injured patients

BACKGROUND

The aim of this review was to assess the value of immediate total-body computed tomography (CT) during the primary survey of injured patients compared with conventional radiographic imaging supplemented with selective CT.

METHODS

A systematic search of the literature was performed in MEDLINE, Embase, Web of Science and Cochrane Library databases. Reports were eligible if they contained original data comparing immediate total-body CT with conventional imaging supplemented with selective CT in injured patients. The main outcomes of interest were overall mortality and time in the emergency room (ER).

RESULTS

Four studies were included describing a total of 5470 patients; one study provided 4621 patients (84.5 per cent). All four studies were non-randomized cohort studies with retrospective data collection. Mortality was reported in three studies. Absolute mortality rates differed substantially between studies, but within studies mortality rates were comparable between immediate total-body CT and conventional imaging strategies (pooled odds ratio 0.91, 95 per cent confidence interval 0.79 to 1.05). Time in the ER was described in three studies, and in two was significantly shorter in patients who underwent immediate total-body CT: 70 versus 104 min (P = 0.025) and 47 versus 82 min (P < 0.001) respectively.

CONCLUSION

This review showed differences in time in the ER in favour of immediate total-body CT during the primary trauma survey compared with conventional radiographic imaging supplemented with selective CT. There were no differences in mortality. The substantial reduction in time in the ER is a promising feature of immediate total-body CT but well designed and larger randomized studies are needed to see how this will translate into clinical outcomes.