title: Who Orders a Head CT?: Perceptions of the Cirrhotic Bleeding Risk in an International, Multispecialty Survey Study.
abstract: OBJECTIVE
  Traditional coagulopathic indices, including elevated international normalized ratio, do not correlate with bleeding risk in patients with cirrhosis. For this reason, head computed tomography (CT) has a low yield in cirrhotic patients with altered mental status and no trauma history. The initial diagnostic evaluation, however, is often made by nongastroenterologists influenced by the so-called "coagulopathy of cirrhosis." We sought to examine the prevalence, impact, and malleability of this perception in an international, multispecialty cohort.
  
  
  METHODS
  An electronic survey was distributed to internal medicine, surgery, emergency medicine, and gastroenterology physicians. Respondents were presented with a cirrhotic patient with hepatic encephalopathy, no history of trauma, and a nonfocal neurological examination. Respondents rated likelihood to order head CT at presentation, after obtaining labs [international normalized ratio (INR) 2.4 and platelets 59×10/μL], and finally after reading the results of a study demonstrating the low yield of head CT in this setting.
  
  
  RESULTS
  In total, 1286 physicians from 6 countries, 84% from the United States. Of these, 62% were from internal medicine, 25% from emergency medicine, 8% from gastroenterology, and 5% from surgery. Totally, 47% of respondents were attending physicians. At each timepoint, emergency physicians were more likely, and gastroenterologists less likely, to scan than all other specialties (P<0.0001). Evidence on the low yield of head CT reduced likelihood to scan for all specialties. Qualitative analysis of open-ended comments confirmed that concern for "coagulopathy of cirrhosis" motivated CT orders.
  
  
  CONCLUSIONS
  Perceptions regarding the coagulopathy of cirrhosis, which vary across specialties, impact clinical decision-making. Exposure to clinical evidence has the potential to change practice patterns.
authors.affiliation: *Goodman Surgical Education Center, Stanford University School of Medicine, Stanford, CA †Department of Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland ‡Department of Medicine, Beth Israel Deaconess Medical Center, Division of Gastroenterology/Hepatology, Harvard Medical School, Boston, MA.
authors.forename: Laura M
authors.initials: LM
authors.lastname: Mazer
authors.forename: Marie
authors.initials: M
authors.lastname: Méan
authors.forename: Elliot B
authors.initials: EB
authors.lastname: Tapper
mesh_terms: D001778:Blood Coagulation Disorders / Q000000981:diagnostic imaging* / Q000209:etiology; D001921:Brain / Q000000981:diagnostic imaging*; D002170:Canada; D002983:Clinical Competence; D000066491:Clinical Decision-Making; D003430:Cross-Sectional Studies; D005060:Europe; D019538:Health Care Surveys; D006501:Hepatic Encephalopathy / Q000000981:diagnostic imaging* / Q000209:etiology; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D016017:Odds Ratio; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011446:Prospective Studies; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*; D014481:United States