Modelling implementation of a clinical decision rule to identify children at very low risk of significant intra-abdominal injury after blunt trauma:

• Saved on average US$55 per child.
• Avoided a CT scan in 1 in 10 children.
• Missed 1 in 2,000 intra-abdominal injuries requiring acute intervention.

summary

• Daniel K Nishijima, Zhuo Yang, John A Clark, Nathan Kuppermann, James F Holmes, and Joy Melnikow.
• Department of Emergency Medicine, U.C. Davis School of Medicine, Sacramento, CA.
• Acad Emerg Med. 2013 Nov 1; 20 (11): 1131-8.

ObjectivesRecently a clinical decision rule (CDR) to identify children at very low risk for intraabdominal injury needing acute intervention (IAI) following blunt torso trauma was developed. Potential benefits of a CDR include more appropriate abdominal computed tomography (CT) use and decreased hospital costs. The objective of this study was to compare the cost-effectiveness of implementing the CDR compared to usual care for the evaluation of children with blunt torso trauma. The hypothesis was that compared to usual care, implementation of the CDR would result in lower CT use and hospital costs.MethodsA cost-effectiveness decision analytic model was constructed comparing the costs and outcomes of implementation of the CDR to usual care in the evaluation of children with blunt torso trauma. Probabilities from a multicenter cohort study of children with blunt torso trauma were derived; estimated costs were based on those at the study coordinating site. Outcome measures included missed IAI, number of abdominal CT scans, total costs, and incremental cost-effectiveness ratios. Sensitivity analyses varying imputed probabilities, costs, and scenarios were conducted.ResultsUsing a hypothetical cohort of 1,000 children with blunt torso trauma, the base case model projected that the implementation of the CDR would result in 0.50 additional missed IAIs, a total cost savings of $54,527, and 104 fewer abdominal CT scans compared to usual care. The usual care strategy would cost $108,110 to prevent missing one additional IAI. Findings were robust under multiple sensitivity analyses.ConclusionsCompared to usual care, implementation of the CDR in the evaluation of children with blunt torso trauma would reduce hospital costs and abdominal CT imaging, with a slight increase in the risk of missed intraabdominal IAI.© 2013 by the Society for Academic Emergency Medicine.

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