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Patient Safety Tip
of the Week
September
21, 2021
Repeat
CT in Anticoagulated Patients After Minor Head Trauma Not Cost-Effective
One
topic that has remained controversial over the years is how often delayed
intracranial hemorrhage occurs in anticoagulated patients who suffer blunt head
trauma. In several of our columns we have described cases where patients did
develop subdural hematomas after they had an initially negative CT scan. But
most case series have demonstrated that the overall risk is quite low.
A new
study (Borst 2021) identified patients in a trauma registry
who were on antithrombotic (anticoagulant and antiplatelet) medications during
a 5-y period and who underwent a head computed tomography for blunt trauma. Per
their institution protocol, patients with an initial negative head computed
tomography underwent repeat imaging 6 hours after their initial head computed
tomography. All patients were admitted to the trauma service and observed for
12 to 24 hours with neurologic checks every 2 hours.
The
initial head computed tomography was negative in 82% of 1,377 patients. Of
those with an initial negative head computed tomography, 12 patients (0.9%)
developed an intracranial hemorrhage that was identified on the second head
computed tomography (6 had intraventricular hemorrhage, 3 had subdural
hematoma, 2 had subarachnoid hemorrhage, and 1 had an intraparenchymal
hemorrhage). None of the patients with delayed intracranial hemorrhage
developed a change in neurologic status, required an intracranial pressure
monitor, or underwent neurosurgical intervention.
Although delayed intracranial hemorrhage was more common in
patients on anticoagulants than on antiplatelet agents, the study was not
powered to detect a difference between these two groups. The authors also note
that, given the small percentage of patients with known INRs in the supratherapeutic range, their results may not apply to
patients with supratherapeutic INR levels.
The
estimated total direct cost of the negative head computed tomography scans was
$926,247. Applying their findings to a hypothetical case where a delayed
intracranial hemorrhage is missed, they estimated the ICER per QALY at
$132,321, not meeting the generally accepted criteria for cost-effectiveness.
Well
note that the methodology used likely overestimated the potential cost savings.
The authors estimated the cost of negative head CTs by multiplying the average
charge for a noncontrast head CT scan ($2,179) by the
Healthcare Cost and Utilization Project cost-to-charge ratio. If you are a
trauma center (the study institution was a Level 1 Trauma Center) and have
round-the-clock radiology staffing, your actual marginal cost for doing that
second non-contrast CT scan is actually quite small.
Even if you have to call in a radiology tech, the
marginal cost is probably considerably lower than their calculated value.
Nevertheless, we all like to avoid any study that adds little value.
Based
on the findings of their study, the institutional protocol at the study
institution was updated. Repeat head CT scans are no longer performed unless
the patient has an INR
>3.5
or a mental status decline on neuro checks performed every 2 hours during their
12- to 24-hour admission for observation.
The
results of the study are reassuring. One question still unanswered is the
optimal timing of the initial CT scan. Perhaps it might make sense to delay the
initial scan in patients who are alert, not drowsy, and having no neurological
signs to 6 hours. But a key to clinical management of these patients was that
they did observe the patients for 24 hours, with neuro checks performed every 2
hours.
We
should also note that the many clinical decision rules on deciding which
patients with minor head trauma should get CT scans do not apply to patients on
anticoagulants.
Some of our previous columns on head trauma
in the anticoagulated patient:
April
16, 2007 Falls With Injury
July
17, 2007 Falls in Patients on Coumadin or Heparin or
Other Anticoagulants
June 5, 2012 Minor
Head Trauma in the Anticoagulated Patient.
July 8, 2014
Update:
Minor Head Trauma in the Anticoagulated Patient
August 21, 2018 Delayed CT Scan in the Anticoagulated Patient
Some of our previous columns on CT scans in
minor head trauma:
April
16, 2007 Falls With Injury
July
17, 2007 Falls in Patients on Coumadin or Heparin or
Other Anticoagulants
March 2010 CATCH:
New Clinical Decision Rule for CT in Pediatric Head Trauma
November 23, 2010 Focus
on Cumulative Radiation Exposure
June 5, 2012 Minor
Head Trauma in the Anticoagulated Patient.
July 8, 2014
Update:
Minor Head Trauma in the Anticoagulated Patient
January 2017 Still Too Many CT Scans for Pediatric
Appendicitis
March 2017
Update on CT Scanning after Minor Head Trauma
September 2017 Clinical Decision Rule Success
August 21, 2018 Delayed CT Scan in the Anticoagulated Patient
References:
Borst
J, Godat LN, Berndtson AE,
et al. Repeat head computed tomography for anticoagulated patients with an
initial negative scan is not cost-effective. Surgery 2021; 170(2): 623-627
Published online: March 26, 2021
https://www.surgjournal.com/article/S0039-6060(21)00117-3/fulltext
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