ABSTRACT
OBJECTIVE: To compare immediate computed tomography during triage for admission with observation in hospital in patients with mild head injury. DESIGN: Multicentre, pragmatic, non-inferiority randomised trial. SETTING: 39 acute hospitals in Sweden. PARTICIPANTS: 2602 patients (aged > or = 6) with mild head injury. INTERVENTIONS: Immediate computed tomography or admission for observation. MAIN OUTCOME MEASURE: Dichotomised extended Glasgow outcome scale (1-7 v 8). The non-inferiority margin was 5 percentage points. RESULTS: At three months, 275 patients (21.4%) in the computed tomography group had not recovered completely compared with 300 (24.2%) admitted for observation. The difference was - 2.8 percentage points, non-significantly in favour of computed tomography (95% confidence interval - 6.1% to 0.6%). The worst outcomes (mortality and more severe loss of function) were similar between the groups. In the patients admitted for observation, there was a considerable delay in time to treatment in those who required surgery. None of the patients with normal findings on immediate computed tomography had complications later. Patients' satisfaction with the two strategies was similar. CONCLUSIONS: The use of computed tomography in the management of patients with mild head injury is feasible and leads to similar clinical outcomes compared with observation in hospital. TRIAL REGISTRATION: ISRCTN81464462.
Subject(s)
Craniocerebral Trauma/diagnostic imaging , Tomography, X-Ray Computed , Adolescent , Adult , Aged , Child , Craniocerebral Trauma/therapy , Female , Hospitalization , Humans , Male , Middle Aged , Prognosis , Risk FactorsABSTRACT
OBJECTIVE: To compare the costs of immediate computed tomography during triage for admission with those of observation in hospital in patients with mild head injury. DESIGN: Prospective cost effectiveness analysis within a multicentre, pragmatic randomised trial. SETTING: 39 acute hospitals in Sweden PARTICIPANTS: 2602 patients (aged > or = 6) with mild head injury. INTERVENTIONS: Immediate computed tomography or admission for observation. MAIN OUTCOME MEASURES: Direct and indirect costs related to the mild head injury during the acute and three month follow-up period. RESULTS: Outcome after three months was similar for both strategies (non-significantly in favour of computed tomography). For the acute stage and complications, the cost was 461 euros (314 pounds sterling, 582 dollars) per patient in the computed tomography group and 677 euros (462 pounds sterling, 854 dollars) in the observation group; an average of 32% less in the computed tomography group (216 euros, 95% confidence interval -272 to -164; P < 0.001). Sensitivity analysis showed that computed tomography was the most cost effective strategy under a broad range of assumptions. After three months, total costs were 718 euros and 914 euros per patient-that is, 196 euros less in the computed tomography group (- 281 to - 114; P < 0.001). The lower cost of the computed tomography strategy at the acute stage thus remained unchanged during follow-up. CONCLUSION: Patients with mild head injury attending an emergency department can be managed more cost effectively with computed tomography rather than admission for observation in hospital. TRIAL REGISTRATION: ISRCTN81464462.
Subject(s)
Craniocerebral Trauma/diagnostic imaging , Tomography, X-Ray Computed/economics , Adolescent , Adult , Aged , Child , Costs and Cost Analysis , Craniocerebral Trauma/economics , Follow-Up Studies , Hospitalization/economics , Humans , Middle Aged , Prospective Studies , SwedenSubject(s)
Brain Concussion/diagnostic imaging , Brain/radiation effects , Tomography, X-Ray Computed , Child , Child Abuse/diagnosis , Child, Preschool , Cognition Disorders/etiology , Contraindications , Humans , Infant , Radiation Dosage , Radiation Injuries/etiology , Risk Factors , Tomography, X-Ray Computed/adverse effectsSubject(s)
Health Care Costs , Obesity/economics , Budgets , Cost of Illness , Humans , Obesity/complications , SwedenSubject(s)
European Union/organization & administration , International Cooperation , Models, Educational , Research Personnel/education , Technology Assessment, Biomedical/methods , Training Support , Curriculum , Data Collection , Education, Distance , Europe , Health Services Research , Humans , Internet , Meta-Analysis as Topic , Program EvaluationABSTRACT
OBJECTIVE: A recurring question is whether evidence from systematic reviews has any impact on medical practice. We have studied this question in relation to some conclusions in seven reports, where relatively simple means to monitor trends could be used. RESULTS: As recommended, in the report preoperative routines, the number of preoperative examinations diminished at six hospitals, during around 3,000 operations studied, a savings of SEK 130 million. After the report on moderately elevated blood pressure, moderately elevated blood pressure sales of the preferred drugs, diuretics and beta-blockers, stopped falling while calcium blockers and ACE inhibitors stopped rising. As concluded in the report, general prostate cancer screening has not been introduced, but tests as a sign of opportunistic screening have increased. Bone density measurements were not recommended for screening, and sales of equipment have declined after the report. The use of neuroleptics as unspecific calming therapy for old persons was discouraged due to the serious side effects. The frequency of patients given this medication diminished from 34% to 28% at nursing homes after 1 year. For smoking cessation, the use of nicotine substitution medications has increased, which is in line with suggestions presented in the report. For stomach pain proton pump inhibitors given for functional dyspepsia have diminished in a region of the country after special efforts to disseminate the message. CONCLUSIONS: It appears to be possible to monitor changes in practice corresponding to selected conclusions in systematic reviews. After rather extensive disseminating efforts, some results look encouraging.
