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Pandor A, Goodacre S, Harnan S, et al. Diagnostic Management Strategies for Adults and Children with Minor Head Injury: A Systematic Review and an Economic Evaluation. Southampton (UK): NIHR Journals Library; 2011 Aug. (Health Technology Assessment, No. 15.27.)

2Research questions

Rationale for the study

The diagnostic management of MHI, particularly the use of CT scanning and hospital admission, involves a trade-off between the benefits of early accurate detection of ICI and the costs and harms of unnecessary investigation and admission for patients with no significant ICI. Clinical assessment, particularly if structured in the form of a decision rule, can be used to select patients for CT scanning and/or admission. Selective use of investigations or admission can reduce resource use, but may increase the risk of missed pathology. Cost-effectiveness analysis is therefore necessary to determine what level of investigation represents the most efficient use of health-care resources.

Although primary research can provide accurate estimates of the cost-effectiveness of alternative strategies, it can only compare a limited number of alternatives and is often restricted by ethical and practical considerations. Economic modelling allows comparison of a wide range of different strategies, including those that might currently be considered impractical or unethical, but may be revealed to be appropriate alternatives. Economic modelling is also a much cheaper and quicker way of comparing alternative strategies than primary research, so it can be used to identify which alternatives are most promising and where uncertainty exists and, thus, where primary research is best focused.

Economic modelling needs to be based upon systematic synthesis of robust and relevant data. We therefore planned to systematically review the literature to identify studies that evaluated the diagnostic accuracy of clinical assessment, decision rules and diagnostic tests used in MHI and studies that compared the outcomes of different diagnostic management strategies. These data could then be used to populate an economic model that estimated the costs and outcomes of potential strategies for managing patients with MHI and identify the optimal strategy for the NHS.

We limited our study to the diagnosis of acute conditions arising from MHI (the accuracy of tests for identifying acute injuries and the costs and benefits of identifying and treating acute injuries). Chronic subdural haematoma can develop weeks after MHI with an initially normal CT scan. As diagnosis and management of this condition occurs after initial presentation, it is more appropriately analysed as part of a separate decision-making process that is beyond the scope of this review. Similarly, we did not explore issues related to diffuse brain injury or persistent symptoms related to mild traumatic brain injury (TBI).

Overall aims and objectives of assessment

The overall aim was to use secondary research methods to determine the most appropriate diagnostic management strategy for adults and children with minor (GCS 13–15) head injury in the NHS. More specifically, the objectives were:

  1. To undertake systematic reviews to determine (1) the diagnostic performance of published clinical decision rules for identifying ICI (including the need for neurosurgery) in adults and children with MHI; (2) the diagnostic accuracy of individual clinical characteristics for predicting ICI (including the need for neurosurgery) in adults and children with MHI; and (3) the comparative effectiveness of different diagnostic management strategies for MHI in terms of process measures (hospital admissions, length of stay, time to neurosurgery) or patient outcomes.
  2. To use a cross-sectional survey and routinely available data to describe current practice in the NHS, in terms of guidelines and management strategies used and hospital admission rates.
  3. To develop an economic model to (1) estimate the cost-effectiveness of diagnostic strategies for MHI, in terms of the cost per quality-adjusted life-year (QALY) gained by each strategy; (2) identify the optimal strategy for managing MHI in the NHS, defined as the most cost-effective strategy at the NICE threshold for willingness to pay per QALY gained; and (3) identify the critical areas of uncertainty in the management of MHI, where future primary research would produce the most benefit.
© 2011, Crown Copyright.

Included under terms of UK Non-commercial Government License.

Cover of Diagnostic Management Strategies for Adults and Children with Minor Head Injury: A Systematic Review and an Economic Evaluation
Diagnostic Management Strategies for Adults and Children with Minor Head Injury: A Systematic Review and an Economic Evaluation.
Health Technology Assessment, No. 15.27.
Pandor A, Goodacre S, Harnan S, et al.
Southampton (UK): NIHR Journals Library; 2011 Aug.

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