We’re back with another patient-oriented clinical decision aid from the folks who brought you Chest Pain Choice – Pediatric Head CT Choice! In this episode, our noble heroes are out to educate parents regarding the risk of intracranial injury in children who are at “intermediate risk” for clinically-important traumatic brain injury by PECARN criteria.
In this multicenter, cluster-randomized, controlled-trial, these authors tested an information graphic and educational tool against usual care, with a primary outcome of parental knowledge. Additional measures of engagement in the decision-making processes, decisional conflict, and parental trust were measured as secondary outcomes related to the cognitive aspects, along with patient-oriented outcomes such as ciTBI and imaging utilization. They included 172 clinicians at 7 sites, and enrolled 971 patients, including 516 patients who consented for recording of their discussion regarding imaging. Follow-up by telephone was obtained in 890 (92%) of patients, with the remainder of outcomes assessment limited to electronic health record and vital records follow-up.
The results are mostly good news regarding the decision aid. Parents in the intervention arm could answer 6 of 10 questions about their choice correctly, compared with 5 of 10 receiving usual care. Secondary cognitive outcomes also favored the decision instrument, and physicians surveyed were generally in favor of the decision aid, as well. Imaging at the index visit was similar between the two groups, but downstream healthcare resource use and subsequent imaging was lower in the decision aid cohort.
There are findings here to critique, of course. There was only one ciTBI in the entire cohort, and they were imaged at the index visit. The expectation – and the tool – were constructed based on a 0.9% ciTBI rate, when the actual observed incidence was 0.1%. It is reasonable to consider the practical implementation of PECARN over-classifies patients into the “intermediate risk” cohort, placing additional children at risk for unneeded imaging – which, in turn, renders their “1 in 100” information graphic misleading. Then, clinicians spent an extra 2 minutes – 38% longer – with parents when using the decision aid. How much of the improved knowledge and trust stems from the decision aid, and how much from simply spending more time in the discussion? Finally, there are uncertain manifestations of the Hawthorne effect, particularly considering over half the encounters were recorded.
Overall, however, I have few quibbles with this decision aid. At the least, it is unlikely to exert a negative effect on parental knowledge or paradoxically increase unnecessary scanning.
“Effect of the Head Computed Tomography Choice Decision Aid in Parents of Children With Minor Head Trauma”
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2703135