New Tool Aids CT Decision-Making in Kids With Mild TBI

Deborah Brauser

October 12, 2018

A new tool may help clinicians and parents work together to make decisions about whether children with minor head trauma (HT) should undergo computed tomography (CT), new research suggests.

Although the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules have recommended no CT for children at very low risk for clinically important traumatic brain injuries (TBIs), they "provide little guidance in the choice of home observation or CT" in children deemed to be at intermediate risk, investigators report

A new cluster randomized trial, which included 172 clinicians caring for almost 1000 children, showed that parents had greater knowledge about the situation, increased engagement, and less decisional conflict when shared decision-making with the Head CT Choice decision aid was used vs usual care.

The rate of emergency department (ED) CT use did not differ between the two groups, but the number of imaging tests conducted 1-week post-injury was significantly lower in the decision-aid group.

In other words, use of the decision aid "improved decisional quality and safely decreased downstream healthcare utilization," the researchers report.

Erik P. Hess, MD

Lead author Erik P. Hess, MD, professor of emergency medicine, University of Alabama at Birmingham, told Medscape Medical News that this particular finding was surprising.

"However, it makes sense that when parents are educated and better equipped to care for their child, they would less frequently seek care and investigation after leaving the ED," said Hess.

Overall, "we designed this aid to help clinicians and parents work together to make risk-informed decisions about obtaining a head CT that weren't driven unduly by emotion or anxiety," he added.

The findings were published online September 21 in JAMA Network Open.

"Lost in Translation"

More than 450,000 children in the United States present to EDs for evaluation of HT, the investigators note. They add that although 37% to 59% of children with minor HT, defined as scores of 14 to 15 on the Glasgow Coma Scale, undergo CT imaging, less than 10% show evidence of TBI on the scans.

"Parents want to participate in their child's medical decisions but physicians have not been ideally equipped to communicate to parents all the factors that would influence a decision to obtain a head CT for a child with a head injury," Hess said.

"Sometimes things are 'lost in translation,' when a clinician will explain something and not realize that the parent isn't understanding because language isn't being used that they are comfortable with," he added.

"So we wanted to provide a standardized way to communicate with parents so they are reassured about the diagnostic decisions for their child."

Between April 2014 and September 2016, the new trial was conducted in seven EDs in the United States. It included 172 clinicians, including attending physicians, pediatric emergency medicine fellows, and advanced practitioners.

These clinicians were caring for 971 children between the ages of 2 and 18 years (mean age, 6.7 years; 59% boys) who had minor HT at intermediate risk for clinically important TBI. They were randomly assigned to the decision-aid group (n = 88, caring for 493 children) or to the usual-care group (n = 84, caring for 478 children).

The Head CT Choice decision aid was developed by the investigators and "educates caregivers regarding the definition of a concussion and differences with other forms of TBIs," as well as providing information on risk for TBI and cranial CT vs active observation advantages/disadvantages, the researchers explain. It also notes signs and symptoms in the patient that should lead to a return visit to the ED.

Clinicians assigned to the decision-aid group were trained in its use through discussions and a video demonstration. They would then bring the aid to a patient's bedside for a decision-making discussion with the parents.

The tool was designed with the influence of both clinicians and parents "to help them learn to speak a common language," Hess said.

In the other group, clinicians discussed management options with parents "according to each clinician's usual fashion," the investigators report.

Parental knowledge, of a child's risk for TBI and of available diagnostic options, was the primary outcome measure. Decisional conflict, ED CT rate, 7-day healthcare use, missed TBIs, and parental involvement in decision-making were all secondary outcomes.

Less Conflict, More Trust

Results showed that parents in the decision-aid group had lower mean scores on the decisional conflict scale than parents in the usual-care group (14.8 vs 19.2, respectively; mean difference, -4.4; 95% CI, -7.3 to -2.4; P < .001).

They also had greater knowledge, as shown by answering more questions correctly (6.2 out of 10 vs 5.3, respectively; P < .001), and had higher scores on the observing patient involvement (OPTION) scale (mean score, 25.0 vs 13.3; P < .001) and validated trust in physician scale (mean score, 91.5 vs 89.3; P = .02).

Between the decision-aid and usual-care groups, the ED CT rate did not differ significantly (22% vs 24%, respectively; odds ratio [OR], 0.81; 95% CI, 0.51 - 1.27), nor did the rate of CT scanning within 7 days (24% vs 26%; OR, 0.81).

However, the mean number of imaging procedures and number of blood tests within 7 days after injury were lower in the decision-aid group (P = .045 and .046, respectively), as was the ED length of stay (176 vs 199 minutes; P = .02).

"It is possible that parents who were engaged in imaging decisions using the decision aid were in closer communication with their care team, facilitating more timely discharge," the researchers write.

In the decision-aid group, diagnostic discussions with parents took an average of 2 minutes longer than in the usual-care group (P < .001). There were no missed TBIs in either group.

"To our knowledge, this is the largest multicenter trial of a shared decision-making intervention and the first to test an intervention in parents seeking emergency care for children with minor head trauma," the investigators write.

"The magnitude of the differences in parent knowledge, decisional conflict, and parent involvement observed in this trial is similar to prior trials of encounter-level decision aids. These findings suggest that the decision aid improved decisional quality as intended," they add.

Hess noted that the decision aid is freely available to download from the Mayo Clinic National Shared Decision Making Resource Center.

"I'd say the takeaway message for clinicians is give the decision aid a try and be willing to engage in a new conversation with parents that may be different from what you've done previously," he said. "Getting physicians comfortable enough to try something new and facilitate a new conversation is really the first step."

"Practical" Communication Tool

In an accompanying editorial, M. Denise Dowd, MD, Division of Emergency Medicine at Children's Mercy Hospital, Kansas City, Missouri, notes that implementing the PECARN head injury guidelines has led to "a safe decrease" in head CT use; and the guidelines consider parental preference as one of the decision factors.

"A parent's preference for whether their child receives a head CT is shaped by many factors including past experience, knowledge, anxiety, and trust in their child's healthcare clinician," she writes. "The content and quality of the communication between the parent and the clinician is intimately tied to these factors."

However, the PECARN guidelines do not provide assistance in determining parental preference.

"Hess and colleagues demonstrate the potential helpfulness of a practical communication tool," Dowd writes.

Although the findings did not show a reduction in head CT rates, this "could be explained by the fact participating sites were already using the PECARN guidelines prior to the study. Use of the decision aid at sites not using the guidelines might demonstrate a different association with physician ordering of head CTs," she adds.

Limitations included that neither specifics or quantification of the risk of head CT radiation were reported. Other questions not answered center around the "impact of racial and ethnic discordance between patient and clinician," the possible influence of parental education and socioeconomic status, and the impact on physician productivity from shared decision-making (SDM) tools.

"While many questions remain on the use of SMD tools in pediatric acute care settings, tools which have the potential to support accurate and complete communication and engage parents in decision-making in busy [EDs] are more than welcome," Dowd writes.

The study was funded through a Patient-Centered Outcomes Research Institute Award. Hess has reported receiving grants from the funder during the conduct of the study. A full list of disclosures for the other authors is listed in the article. Dowd has reported no relevant financial relationships.

JAMA Network Open. Published online September 21, 2018. Full article, Editorial

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