Erik P. Hess, James L. Homme, Anupam B. Kharbanda, Leah
Tzimenatos, Jeffrey P. Louie, Daniel M. Cohen, Lise E. Nigrovic, Jessica J.
Westphal, Nilay D. Shah, Jonathan Inselman, Michael J. Ferrara, Jeph Herrin, Victor
M. Montori, Nathan Kuppermann. Effect of
the Head Computed Tomography Choice Decision Aid in Parents of Children With
Minor Head Trauma. A Cluster Randomized
Trial. JAMA Network Open.
2018;1(5):e182430. doi:10.1001/jamanetworkopen.2018.2430
Key Points
Question What is the
effect of a decision aid in parents of children with minor head trauma?
Findings In this
cluster randomized trial of 172 clinicians caring for 971 children at
intermediate risk of traumatic brain injury, the Head Computed Tomography
Choice decision aid increased parental knowledge, decreased decisional
conflict, and increased engagement. The intervention did not reduce the
emergency department computed tomography rate but safely decreased 7-day health
care utilization.
Meaning Use of a
decision aid in parents of children with minor head trauma had no effect on the
emergency department computed tomography rate, but improved decisional quality
and safely decreased downstream health care utilization.
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.
_________________________________________________________________________
"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."…
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…
"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."…
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."
https://www.medscape.com/viewarticle/903347
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