CT Imaging for Minor Head Injury Is Overused

One in every three computerized tomography (CT) scans performed in the emergency department (ED) for patients presenting with minor head injury is not medically necessary, according to a new study.

Researchers at Yale School of Medicine (New Haven, CT, USA), the Mayo Clinic (Rochester, MN, USA), and other institutions conducted a qualitative study in three phases to identify nonclinical, human factors that promote or inhibit appropriate use of CT in ED patients with minor head injury. Focus groups of patients and providers were conducted until thematic saturation was reached.

The findings from the focus groups were then triangulated with a cognitive task analysis, including direct observation in the ED and individual, semi-structured, interviews using the critical decision method with four senior physician subject matter experts. Focus groups and interview notes were analyzed using an iterative coding process to determine themes. Finally, the data were double-coded and examined for discrepancies to establish consensus. The researchers thus found that a range of nonclinical factors influenced medical decisions leading to unnecessary scans.

For providers, those factors included their own lack of confidence and experience, the influence of others (family members and other providers), and time constraints. For patients, empathic themes such as the doctor’s ability to listen and care for them were significant issues. To address those factors the researchers noted themes involving trust and bedside manner, which include patient engagement, listening, reassurance, identifying and addressing patient concerns, and managing patient anxiety. The study was published on November 14, 2015, in Academic Emergency Medicine.

“The doctor-patient relationship weighs heavily on the ability of the doctor and patient to be aligned in terms of whether a patient will understand and agree with the doctor’s recommendation,” said lead author Edward Melnick MD, of the Yale department of emergency medicine. “When a doctor takes time to listen and care for a patient, and the patient sees the doctor cares, the patient is more willing to trust the doctor’s recommendation whether CT scan is indicated.”

Five core domains to reduce CT overuse emerged from the analysis: establishing trust, reducing anxiety (both patient and provider), establish constraints related to ED practice, reduce the influence of others, and acknowledge patient expectations. Key themes within these core domains included patient engagement, provider confidence and experience, the ability to identify and manage patient anxiety, time constraints, concussion knowledge gap, influence of health care providers, and patient expectations to get a CT.

Related Links:
Yale School of Medicine
Mayo Clinic