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The patients were adequately randomized.The study population included or focused on those in the emergency department.Chris Carpenter to determine which checklist was the most appropriate to use. Quality Checklist for Randomized Clinical Trials:Īlthough this is an RCT, it is different from our usual RCTs, and some of the questions on our check list aren’t as applicable as when we look at RCTs of therapeutic interventions. Critical appraisal is always complex, and even the two of us had to turn to a true expert in Dr. This work is preliminary, hypothetical, and requires confirmation in larger patient cohorts facing these actual decisions.” Jessica is planning on going into emergency medicine after she graduates in the spring. Publishing in AEM should certainly help with her application.Īuthors’ Conclusions: “ Providing financial incentives to forego testing significantly decreased patient preference for testing, even when accounting for test benefit and risk. She is a fourth-year medical student at the University of Michigan. Jessica Winkels is the second author on this AEM publication and also joins us on the podcast. Secondary Outcome: They performed multiple regressions to control for potential confounders.Primary Outcome: The percentage of patients that chose to receive a CT scan.All risk and benefit information were provided in multiple formats, include percentages (0.1%), ratios (1 in 1,000), and in visual depictions.Incentive: Patients were offered either $100 to forgo the CT, or $0.Risk: This was presented as either 1% or 0.1%.Benefit: This was presented as either 1% or 0.1%.Three aspects of the scenario were randomized: The scenario was designed such that the Canadian Head CT rule suggests against imaging. Intervention and Comparison: Patients were all presented with a hypothetical low risk head trauma scenario.
They also excluded patients with altered mental status, with contact precautions, or in resuscitation bays. Exclusions : Patients with chest pain or head trauma (because those were the conditions in the hypothetical cases presented).Population: A convenience sample of adult patients presenting to the University of Michigan emergency department.The Effect of Financial Incentives on Patient Decisions to Undergo Low-value Head Computed Tomography Scans. Ĭlinical Question:Do financial incentives, together with potential risk and potential benefit information, influence patient preference for diagnostic testing? This study by Iyengar and colleagues examines the impacts of financial incentives, as well as varying levels of risk and benefit, on patient preference for CT imaging in the setting of low risk head injury. Thus, it is important to know what factors influence patients’ decision to undergo CT. In addition, if we are working in a zero-miss culture, we may be more likely to order CT scans that are not medically necessary. For these patients, shared decision making is probably the best route forward.Įven when it seems clear to the physician that imaging isn’t required, we can be met with resistance from our patients. There is a great deal of uncertainty in emergency medicine, which leaves a sizeable number of patients in a grey zone – where harms and benefits are closely matched, qualitatively different, or just unknown. However, further, high quality prospective studies are required prior to clinical application. The bottom line was that this paper opens the door for further research to try to narrow the criteria in the CCHR to further reduce unnecessary head CT imaging in the emergency department. We also recently reviewed a paper that looked at increasing the CCHR age criteria from 65 years of age to 75 years of age ( SGEM#266). The SGEM covered the classic paper on the CCHR by the Legend of Emergency Medicine Dr. One way to decrease CT scans of the head is to use a clinical decision instrument like the Canadian CT Head Rule (CCHR). Many imaging decisions are obvious – the patient either clearly requires or clearly does not require imaging. Not only does unnecessary testing reduce efficiency and add costs, it also directly harms patients with unnecessary radiation. For example, one study that looked retrospectively at all head CTs ordered for trauma concluded that more than 1/3 were unnecessary based on the Canadian CT head rule. However, likely because it is such a valuable tool, there seems to be little doubt that we overuse it.
It allows for incredibly rapid identification of a myriad of life-threatening conditions. Background: The CT scan is arguably one of the most important pieces of diagnostic technology that we use in emergency medicine.
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