Quaas Joshua, Derrick Bruce, Mitrani Lindsey, Baarbe Simon, Yarusi Brett, Wiener Dan, Newman David
Department of Emergency Medicine, St. Luke's-Roosevelt Hospital, New York, NY, United States.
Department of Emergency Medicine, Duke University Medical Center, Durham, NC, United States.
Injury. 2014 Sep;45(9):1503-8. doi: 10.1016/j.injury.2014.05.012. Epub 2014 May 20.
Assess factors that influence both the patient and the physician in the setting of minor head injury in adults and the decision-making process around CT utilization.
This is a convenience sample survey study of adult minor head injury patients (GCS 15) and their physicians regarding factors influencing the decision to use CT to evaluate for intra-cranial haemorrhage. Once a head CT was ordered and before the results were known, both the patient and physician were given a one-page survey asking questions about their concern for injury and rationale for CT use. CT results and surveys were then recorded in a centralized database and analyzed.
584 subjects were enrolled over the 27-month study period. The rate of any intra-cranial haemorrhage was 3.3%. Both the physicians (6% pre-test estimate) and the patients (22% pre-test estimate) over-estimated risk for haemorrhage. Clinical decision rules were not met in 46% of cases where CT was used. Physicians listed an average of 5 factors from a list of 9 that influenced their decision to order CT. Patients listed an average of 1.7 factors influencing their decision to present to the Emergency Department for evaluation. Many patients felt cost (45%) and low risk stratification (34%) should weigh heavily in the decision to use CT. If asked to limit CT utilization, physicians were able to identify a group with less than 2% risk of injury.
Patients with low risk of intra-cranial injury continue to be evaluated by CT. Physician decision-making around the use of CT to evaluate minor head injury is multi-factorial. Shared decision-making between the patient and the physician in a low risk minor head injury encounter shows promise as a method to reduce CT utilization in this low risk cohort.
评估在成人轻度头部损伤情况下影响患者和医生的因素，以及围绕CT使用的决策过程。
这是一项针对成人轻度头部损伤患者（格拉斯哥昏迷量表评分为15分）及其医生的便利抽样调查研究，涉及影响使用CT评估颅内出血决策的因素。一旦开具头部CT检查单且结果未知之前，患者和医生都会收到一份单页调查问卷，询问他们对损伤的担忧以及使用CT的理由。然后将CT结果和调查问卷记录在一个集中数据库中并进行分析。
在为期27个月的研究期间共纳入了584名受试者。颅内出血的发生率为3.3%。医生（预测试估计为6%）和患者（预测试估计为22%）均高估了出血风险。在46%使用CT的病例中未满足临床决策规则。医生从9项因素列表中平均列出了5项影响其开具CT检查单决策的因素。患者平均列出了1.7项影响其前往急诊科进行评估决策的因素。许多患者认为费用（45%）和低风险分层（34%）在使用CT的决策中应占重要权重。如果要求限制CT的使用，医生能够识别出损伤风险低于2%的一组患者。
颅内损伤风险低的患者仍在接受CT评估。医生围绕使用CT评估轻度头部损伤的决策是多因素的。在低风险轻度头部损伤情况下患者和医生之间的共同决策作为一种降低该低风险队列中CT使用的方法显示出前景。
