Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Randomized Controlled Trial
. 2018 Sep 7;1(5):e182430.
doi: 10.1001/jamanetworkopen.2018.2430.

Effect of the Head Computed Tomography Choice Decision Aid in Parents of Children With Minor Head Trauma: A Cluster Randomized Trial

Erik P Hess  1   2   3 , James L Homme  4   5 , Anupam B Kharbanda  6 , Leah Tzimenatos  7 , Jeffrey P Louie  8 , Daniel M Cohen  9 , Lise E Nigrovic  10 , Jessica J Westphal  11 , Nilay D Shah  12   13 , Jonathan Inselman  13 , Michael J Ferrara  2   14 , Jeph Herrin  15 , Victor M Montori  3 , Nathan Kuppermann  6   16
Affiliations
Randomized Controlled Trial

Effect of the Head Computed Tomography Choice Decision Aid in Parents of Children With Minor Head Trauma: A Cluster Randomized Trial

Erik P Hess et al. JAMA Netw Open. .

Abstract

Importance: The Pediatric Emergency Care Applied Research Network prediction rules for minor head trauma identify children at very low, intermediate, and high risk of clinically important traumatic brain injuries (ciTBIs) and recommend no computed tomography (CT) for those at very low risk. However, the prediction rules provide little guidance in the choice of home observation or CT in children at intermediate risk for ciTBI.

Objective: To compare a decision aid with usual care in parents of children at intermediate risk for ciTBI.

Design, settings, and participants: This cluster randomized trial was conducted in 7 geographically diverse US emergency departments (EDs) from April 1, 2014, to September 30, 2016. Eligible participants were emergency clinicians, children ages 2 to 18 years with minor head trauma at intermediate risk for ciTBI, and their parents.

Interventions: Clinicians were randomly assigned (1:1 ratio) to shared decision-making facilitated by the Head CT Choice decision aid or to usual care.

Main outcomes and measures: The primary outcome, selected by parent stakeholders, was knowledge of their child's risk for ciTBI and the available diagnostic options. Secondary outcomes included decisional conflict, parental involvement in decision-making, the ED CT rate, 7-day health care utilization, and missed ciTBI.

Results: A total of 172 clinicians caring for 971 children (493 decision aid; 478 usual care) with minor head trauma at intermediate risk for ciTBI were enrolled. The patient mean (SD) age was 6.7 (7.1) years, 575 (59%) were male, and 253 (26%) were of nonwhite race. Parents in the decision aid arm compared with the usual care arm had greater knowledge (mean [SD] questions correct: 6.2 [2.0] vs 5.3 [2.0]; mean difference, 0.9; 95% CI, 0.6-1.3), had less decisional conflict (mean [SD] decisional conflict score, 14.8 [15.5] vs 19.2 [16.6]; mean difference, -4.4; 95% CI, -7.3 to -2.4), and were more involved in CT decision-making (observing patient involvement [OPTION] scores: mean [SD], 25.0 [8.5] vs 13.3 [6.5]; mean difference, 11.7; 95% CI, 9.6-13.9). Although the ED CT rate did not significantly differ (decision aid, 22% vs usual care, 24%; odds ratio, 0.81; 95% CI, 0.51-1.27), the mean number of imaging tests was lower in the decision aid arm 7 days after injury. No child had a missed ciTBI.

Conclusions and relevance: Use of a decision aid in parents of children at intermediate risk of ciTBI increased parent knowledge, decreased decisional conflict, and increased involvement in decision-making. The intervention did not significantly reduce the ED CT rate but safely decreased health care utilization 7 days after injury.

Trial registration: ClinicalTrials.gov Identifier: NCT02063087.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Drs Hess, Tzimenatos, Nigrovic, and Kuppermann reported grants from the Patient-Centered Outcomes Research Institute during the conduct of the study. Dr Kharbanda reported grants from the Patient-Centered Outcomes Research Institute during the conduct of the study and grants from the National Institutes of Health outside the submitted work. Dr Shah reported grants from the Patient-Centered Outcomes Research Institute during the conduct of the study; and grants from the Agency for Healthcare Research and Quality, Centers for Medicare and Medicaid Innovations, US Food and Drug Administration, and National Science Foundation outside the submitted work. Mr Inselman and Dr Herrin reported personal fees from the Mayo Clinic during the conduct of the study. Dr Kuppermann reported grants from the National Institutes of Health and the Health Resources and Services Administration outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Participant Flow Diagram
EMR indicates electronic medical record; GCS, Glasgow Coma Scale; PECARN, Pediatric Emergency Care Applied Research Network.
Figure 2.
Figure 2.. The Head CT Choice Decision Aid
Decision aid used to facilitate a discussion between clinicians and parents regarding whether to obtain a cranial computed tomography (CT) scan in the emergency department (ED) or to actively observe the child at home. Data used to generate the risk of clinically important brain injury displayed on the decision aid were obtained from an investigation by Kuppermann et al. Used with permission of Mayo Foundation for Medical Education and Research. All rights reserved.
See this image and copyright information in PMC

Comment in

References

    1. Faul M, Xu L, Wald MM, Coronado VG. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002-2006. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010. doi:10.15620/cdc.5571 - DOI
    1. Quayle KS, Powell EC, Mahajan P, et al. . Epidemiology of blunt head trauma in children in U.S. emergency departments. N Engl J Med. 2014;371(20):-. doi:10.1056/NEJMc1407902 - DOI - PubMed
    1. Atabaki SM, Hoyle JD Jr, Schunk JE, et al. . Comparison of prediction rules and clinician suspicion for identifying children with clinically important brain injuries after blunt head trauma. Acad Emerg Med. 2016;23(5):566-575. doi:10.1111/acem.12923 - DOI - PubMed
    1. Miglioretti DL, Johnson E, Williams A, et al. . The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatr. 2013;167(8):700-707. doi:10.1001/jamapediatrics.2013.311 - DOI - PMC - PubMed
    1. Kuppermann N, Holmes JF, Dayan PS, et al. ; Pediatric Emergency Care Applied Research Network . Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170. doi:10.1016/S0140-6736(09)61558-0 - DOI - PubMed

Publication types

Associated data