Monday, October 22, 2018

New tool aids CT decision-making in kids with mild TBI

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.


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."

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