title: Should all anticoagulated patients with head injury receive a CT scan? Decision-analysis modelling of an observational cohort.
abstract: It is not currently clear whether all anticoagulated patients with a head injury should receive CT scanning or only those with evidence of traumatic brain injury (eg, loss of consciousness or amnesia). We aimed to determine the cost-effectiveness of CT for all compared with selective CT use for anticoagulated patients with a head injury.
  
  
  
  Decision-analysis modelling of data from a multicentre observational study.
  
  
  
  33 emergency departments in England and Scotland.
  
  
  
  3566 adults (aged ≥16 years) who had suffered blunt head injury, were taking warfarin and underwent selective CT scanning.
  
  
  
  Estimated expected benefits in terms of quality-adjusted life years (QALYs) were the entire cohort to receive a CT scan; estimated increased costs of CT and also the potential cost implications associated with patient survival and improved health. These values were used to estimate the cost per QALY of implementing a strategy of CT for all patients compared with observed practice based on guidelines recommending selective CT use.
  
  
  
  Of the 1420 of 3534 patients (40%) who did not receive a CT scan, 7 (0.5%) suffered a potentially avoidable head injury-related adverse outcome. If CT scanning had been performed in all patients, appropriate treatment could have gained 3.41 additional QALYs but would have incurred £193 149 additional treatment costs and £130 683 additional CT costs. The incremental cost-effectiveness ratio of £94 895/QALY gained for unselective compared with selective CT use is markedly above the threshold of £20-30 000/QALY used by the UK National Institute for Care Excellence to determine cost-effectiveness.
  
  
  
  CT scanning for all anticoagulated patients with head injury is not cost-effective compared with selective use of CT scanning based on guidelines recommending scanning only for those with evidence of traumatic brain injury.
  
  
  
  NCT 02461498.
authors.affiliation: School of Health and Related Research, University of Sheffield, Sheffield UK.
authors.forename: Maxine
authors.initials: M
authors.lastname: Kuczawski
authors.affiliation: School of Health and Related Research, University of Sheffield, Sheffield UK.
authors.forename: Matt
authors.initials: M
authors.lastname: Stevenson
authors.affiliation: School of Health and Related Research, University of Sheffield, Sheffield UK.
authors.forename: Steve
authors.initials: S
authors.lastname: Goodacre
authors.affiliation: School of Health and Related Research, University of Sheffield, Sheffield UK.
authors.forename: M Dawn
authors.initials: MD
authors.lastname: Teare
authors.affiliation: Emergency Department, Northern General Hospital, Sheffield UK.
authors.forename: Shammi
authors.initials: S
authors.lastname: Ramlakhan
authors.affiliation: Emergency Department, Northern General Hospital, Sheffield UK.
authors.forename: Francis
authors.initials: F
authors.lastname: Morris
authors.affiliation: School of Health and Related Research, University of Sheffield, Sheffield UK.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Mason
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D006259:Craniocerebral Trauma / Q000000981:diagnostic imaging* / Q000188:drug therapy; D003661:Decision Support Techniques; D004636:Emergency Service, Hospital / Q000458:organization & administration; D004739:England; D005260:Female; D023261:Glasgow Outcome Scale; D006801:Humans; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D019057:Quality-Adjusted Life Years; D012606:Scotland; D014057:Tomography, X-Ray Computed / Q000191:economics*; D014859:Warfarin / Q000627:therapeutic use; D055815:Young Adult
chemical_list: D000925:Anticoagulants; D014859:Warfarin
keywords: TRAUMA MANAGEMENT; Warfarin