School of Health and Related Research, The University of Sheffield, United Kingdom.
Injury. 2012 Sep;43(9):1423-31. doi: 10.1016/j.injury.2011.07.017. Epub 2011 Aug 10.
To estimate the cost-effectiveness of diagnostic management strategies for adults with minor head injury.
A mathematical model was constructed to evaluate the incremental costs and effectiveness (Quality Adjusted Life years Gained, QALYs) of ten diagnostic management strategies for adults with minor head injuries. Secondary analyses were undertaken to determine the cost-effectiveness of hospital admission compared to discharge home and to explore the cost-effectiveness of strategies when no responsible adult was available to observe the patient after discharge.
The apparent optimal strategy was based on the high and medium risk Canadian CT Head Rule (CCHRhm), although the costs and outcomes associated with each strategy were broadly similar. Hospital admission for patients with non-neurosurgical injury on CT dominated discharge home, whilst hospital admission for clinically normal patients with a normal CT was not cost-effective compared to discharge home with or without a responsible adult at £39 and £2.5 million per QALY, respectively. A selective CT strategy with discharge home if the CT scan was normal remained optimal compared to not investigating or CT scanning all patients when there was no responsible adult available to observe them after discharge.
Our economic analysis confirms that the recent extension of access to CT scanning for minor head injury is appropriate. Liberal use of CT scanning based on a high sensitivity decision rule is not only effective but also cost-saving. The cost of CT scanning is very small compared to the estimated cost of caring for patients with brain injury worsened by delayed treatment. It is recommended therefore that all hospitals receiving patients with minor head injury should have unrestricted access to CT scanning for use in conjunction with evidence based guidelines. Provisionally the CCHRhm decision rule appears to be the best strategy although there is considerable uncertainty around the optimal decision rule. However, the CCHRhm rule appears to be the most widely validated and it therefore seems appropriate to conclude that the CCHRhm rule has the best evidence to support its use.
评估成人轻度头部损伤的诊断管理策略的成本效益。
构建了一个数学模型，以评估十种成人轻度头部损伤的诊断管理策略的增量成本和效果（获得的质量调整生命年，QALYs）。进行了二次分析，以确定与出院回家相比住院的成本效益，并探讨在没有负责任的成年人可以在出院后观察患者的情况下，策略的成本效益。
基于高风险和中风险加拿大 CT 头部规则（CCHRhm）的明显最佳策略，尽管与每种策略相关的成本和结果大致相似。对于 CT 上有非神经外科损伤的患者，住院治疗优于出院回家，而对于 CT 正常的临床正常患者，与出院回家相比，住院治疗没有成本效益，分别为每位 QALY 花费 39 英镑和 250 万英镑。在没有负责任的成年人可以在出院后观察他们的情况下，与不进行任何调查或对所有患者进行 CT 扫描相比，具有正常 CT 扫描的选择性 CT 策略与出院回家仍然是最佳策略。
我们的经济分析证实，最近扩大了对轻度头部损伤 CT 扫描的获取是合适的。基于高灵敏度决策规则的广泛使用 CT 扫描不仅有效，而且还节省成本。与因延迟治疗而加重的脑损伤患者的护理成本相比，CT 扫描的成本非常小。因此，建议所有接收轻度头部损伤患者的医院都应不受限制地获得 CT 扫描，以便与循证指南一起使用。暂时看来，CCHRhm 决策规则似乎是最佳策略，尽管最佳决策规则存在很大的不确定性。但是，CCHRhm 规则似乎是最广泛验证的规则，因此似乎可以得出结论，CCHRhm 规则具有支持其使用的最佳证据。
