Should all anticoagulated patients with head injury receive a CT scan? Decision-analysis modelling of an observational cohort

Maxine Kuczawski, Matt Stevenson, Steve Goodacre, M Dawn Teare, Shammi Ramlakhan, Francis Morris, Suzanne Mason, Maxine Kuczawski, Matt Stevenson, Steve Goodacre, M Dawn Teare, Shammi Ramlakhan, Francis Morris, Suzanne Mason

Abstract

Objectives: It is not currently clear whether all anticoagulated patients with a head injury should receive CT scanning or only those with evidence of traumatic brain injury (eg, loss of consciousness or amnesia). We aimed to determine the cost-effectiveness of CT for all compared with selective CT use for anticoagulated patients with a head injury.

Design: Decision-analysis modelling of data from a multicentre observational study.

Setting: 33 emergency departments in England and Scotland.

Participants: 3566 adults (aged ≥16 years) who had suffered blunt head injury, were taking warfarin and underwent selective CT scanning.

Main outcome measures: Estimated expected benefits in terms of quality-adjusted life years (QALYs) were the entire cohort to receive a CT scan; estimated increased costs of CT and also the potential cost implications associated with patient survival and improved health. These values were used to estimate the cost per QALY of implementing a strategy of CT for all patients compared with observed practice based on guidelines recommending selective CT use.

Results: Of the 1420 of 3534 patients (40%) who did not receive a CT scan, 7 (0.5%) suffered a potentially avoidable head injury-related adverse outcome. If CT scanning had been performed in all patients, appropriate treatment could have gained 3.41 additional QALYs but would have incurred £193 149 additional treatment costs and £130 683 additional CT costs. The incremental cost-effectiveness ratio of £94 895/QALY gained for unselective compared with selective CT use is markedly above the threshold of £20-30 000/QALY used by the UK National Institute for Care Excellence to determine cost-effectiveness.

Conclusions: CT scanning for all anticoagulated patients with head injury is not cost-effective compared with selective use of CT scanning based on guidelines recommending scanning only for those with evidence of traumatic brain injury.

Trial registration number: NCT 02461498.

Trial registration: ClinicalTrials.gov NCT02461498.

Keywords: TRAUMA MANAGEMENT; Warfarin.

Conflict of interest statement

Conflicts of Interest: None declared.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Figures

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NICE guidance 2007 versus 2014.

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