Minor head injury: CT-based strategies for management--a cost-effectiveness analysis.
OBJECTIVE
To compare the cost-effectiveness of using selective computed tomographic (CT) strategies with that of performing CT in all patients with minor head injury (MHI).


METHODS
The internal review board approved the study; written informed consent was obtained from all interviewed patients. Five strategies were evaluated, with CT performed in all patients with MHI; selectively according to the New Orleans criteria (NOC), Canadian CT head rule (CCHR), or CT in head injury patients (CHIP) rule; or in no patients. A decision tree was used to analyze short-term costs and effectiveness, and a Markov model was used to analyze long-term costs and effectiveness. n-Way and probabilistic sensitivity analyses and value-of-information (VOI) analysis were performed. Data from the multicenter CHIP Study involving 3181 patients with MHI were used. Outcome measures were first-year and lifetime costs, quality-adjusted life-years, and incremental cost-effectiveness ratios.


RESULTS
Study results showed that performing CT selectively according to the CCHR or the CHIP rule could lead to substantial U.S. cost savings ($120 million and $71 million, respectively), and the CCHR was the most cost-effective at reference-case analysis. When the prediction rule had lower than 97% sensitivity for the identification of patients who required neurosurgery, performing CT in all patients was cost-effective. The CHIP rule was most likely to be cost-effective. At VOI analysis, the expected value of perfect information was $7 billion, mainly because of uncertainty about long-term functional outcomes.


CONCLUSIONS
Selecting patients with MHI for CT renders cost savings and may be cost-effective, provided the sensitivity for the identification of patients who require neurosurgery is extremely high. Uncertainty regarding long-term functional outcomes after MHI justifies the routine use of CT in all patients with these injuries.
Smits
Marion
M
Department of Radiology, Erasmus MC-University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, Rotterdam, the Netherlands.
Dippel
Diederik W J
DW
Nederkoorn
Paul J
PJ
Dekker
Helena M
HM
Vos
Pieter E
PE
Kool
Digna R
DR
van Rijssel
Daphne A
DA
Hofman
Paul A M
PA
Twijnstra
Albert
A
Tanghe
Hervé L J
HL
Hunink
M G Myriam
MG
D003362:Cost-Benefit Analysis / Q000191:economics*; D006259:Craniocerebral Trauma / Q000000981:diagnostic imaging* / Q000191:economics*; D003663:Decision Trees; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008390:Markov Chains; D009010:Monte Carlo Method; D019057:Quality-Adjusted Life Years; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D016019:Survival Analysis; D014057:Tomography, X-Ray Computed / Q000191:economics*