A few months ago, I wrote about the main publication from this study group – a publication in The Lancet detailing a robust performance comparison between the major pediatric head injury decision instruments. Reading between the lines, as I mentioned then, it seemed as though the important unaddressed result was how well physician judgment performed – only 8.3% of the entire cohort underwent CT.
This, then, is the follow-up publication in Annals of Emergency Medicine focusing on the superiority of physician judgment. Just to recap, this study assessed 18,913 patients assessed to have had a mild head injury. Of these, 160 had a clinically important traumatic brain injury and 24 underwent neurosurgery. The diagnostic performance of these decision instruments is better detailed in the other article but, briefly, for ciTBI:
- PECARN – ~99% sensitive, 52 to 59.1% specific
- CHALICE – 92.5% sensitive, 78.6% specific
- CATCH – 92.5% sensitive, 70.4% specific
These rules, given their specificity, would commit patients to CT scan rates of 20-30% in the case of CHALICE and CATCH, and then an observation or CT rate of ~40% for PECARN. But how did physician judgment perform?
- Physicians – 98.8% sensitive, 92.4% specific
Which is to say, physicians missed two injuries – each detected a week later in follow-up for persistent headaches – but only performed CTs in 8.3% of the population. As I highlighted in this past month’s ACEPNow, clinical decision instruments are frequently placed on a pedestal based on their own performance characteristics in a vacuum, and rarely compared with clinician judgment – and, frequently, clinician judgment is as good or better. It’s fair to say these head injury decision instruments, depending on the prevalence of injury and the background level of advance imaging, may actually be of little value.
“Accuracy of Clinician Practice Compared With Three Head Injury Decision Rules in Children: A Prospective Cohort Study”
http://www.annemergmed.com/article/S0196-0644(18)30028-3/fulltext