Royuela Ana, Abad Cristina, Vicente Agustina, Muriel Alfonso, Romera Rut, Fernandez-Felix Borja M, Corres Jesus, Fernandez Bustos Patricia, Ortega Angelica, Heras-Mosteiro Julio, Garcia Latorre Raquel, Zamora Javier
Clinical Biostatistics Unit, Health Research Institute Puerta de Hierro-Segovia de Arana, CIBERESP, Madrid, Spain.
Department of Radiology, Hospital Universitario Ramon y Cajal, Madrid, Spain.
J Emerg Med. 2019 Dec;57(6):780-790. doi: 10.1016/j.jemermed.2019.08.026. Epub 2019 Oct 4.
Nontraumatic headache is a frequent complaint in the emergency department (ED). Cranial computed tomography (CT) is a widely available test for the diagnostic work-up, despite the risk of exposure to ionizing radiation.
We sought to develop and evaluate a cranial CT request computerized decision support system (CDSS) for adults with their first presentation of unusual severe nontraumatic headache in the ED.
Electronic database searches identified clinical decision and prediction rules and studies delineating risk factors in nontraumatic headache. A long list of risk factors extracted from these articles was reduced by a 30-member multidisciplinary expert panel (radiologists, emergency physicians, methodologists), using a 90% agreement threshold. This shortlist was used to develop the algorithm for the cranial CT request CDSS, which was implemented in March 2016. Impact evaluation compared CT scan frequency and diagnostic yield of pathologic findings before (March-August 2015) and after (March-August 2016) implementation.
From the 10 selected studies, 10 risk factors were shortlisted to activate a request for cranial CT. Before implementation, 377 cranial CTs were ordered (15.3% of 2469 CT scans) compared with 244 after (9.5% of 2561 CT scans; pre-post difference 5.74%; 95% confidence interval [CI] 3.92-7.56%; p < 0.001), corresponding to a 37.6% relative reduction in the test ordering rate (95% CI 25.7-49.5%; p < 0.001). Despite the reduction in cranial CT scans, we did not observe an increase in pathological findings after introducing the decision support system (70 cases before [18.5%] vs. 35 cases after [14.3%]; pre-post difference -4.0% [95% CI -10.0 to 1.6%]; p = 0.170).
In nontraumatic headache among adults seen in the ED, CDSS decreased the cranial CT request rate but the diagnostic yield did not improve.
非创伤性头痛是急诊科常见的主诉。尽管存在电离辐射暴露风险，但头颅计算机断层扫描（CT）仍是广泛应用于诊断检查的一项检测。
我们试图开发并评估一种针对首次在急诊科出现异常严重非创伤性头痛的成年人的头颅CT检查申请计算机决策支持系统（CDSS）。
通过电子数据库检索，确定临床决策和预测规则以及描述非创伤性头痛危险因素的研究。由30名多学科专家组成的小组（放射科医生、急诊科医生、方法学家）使用90%的一致性阈值，从这些文章中提取的一长串危险因素清单得以精简。这份入围清单用于开发头颅CT检查申请CDSS的算法，该算法于2016年3月实施。影响评估比较了实施前（2015年3月至8月）和实施后（2016年3月至8月）CT扫描频率和病理结果的诊断率。
从10项选定研究中，筛选出10个危险因素以启动头颅CT检查申请。实施前，共开出377份头颅CT检查单（占2469次CT扫描的15.3%），实施后为244份（占2561次CT扫描的9.5%；前后差异5.74%；95%置信区间[CI]3.92 - 7.56%；p < 0.001），相应的检查申请率相对降低了37.6%（95%CI 25.7 - 49.5%；p < 0.001）。尽管头颅CT扫描次数减少，但引入决策支持系统后，我们并未观察到病理结果增加（之前70例[18.5%]，之后35例[14.3%]；前后差异 -4.0%[95%CI -10.0至1.6%]；p = 0.170）。
在急诊科就诊的成年非创伤性头痛患者中，CDSS降低了头颅CT检查申请率，但诊断率并未提高。
