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Cost-effectiveness of patient observation on cranial CT use with minor head trauma
  1. Sonia Singh1,2,3,
  2. Stephen Hearps4,
  3. Daniel K Nishijima3,
  4. John Alexander Cheek1,2,5,
  5. Meredith Borland6,7,
  6. Stuart Dalziel8,9,
  7. James Holmes3,10,
  8. Nathan Kuppermann3,11,
  9. Franz E Babl1,2,5,
  10. Jeffrey S Hoch10,12
  11. On behalf of the Paediatric Research in Emergency Departments International Collaborative (PREDICT)
  1. 1Department of Paediatrics, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia
  2. 2Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
  3. 3Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California, USA
  4. 4Child Neuropsychology, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
  5. 5Emergency Department, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
  6. 6Emergency Medicine, Perth Children's Hospital, Nedlands, Western Australia, Australia
  7. 7Divisions of Paediatrics and Emergency Medicine, University of Western Australia, Crawley, Western Australia, Australia
  8. 8Emergency Department, Starship Children's Health, Auckland, New Zealand
  9. 9Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
  10. 10Center for Healthcare Policy and Research, University of California Davis Health System, Sacramento, California, USA
  11. 11Department of Pediatrics, University of California Davis School of Medicine, Sacramento, California, USA
  12. 12Department of Public Health Sciences, University of California Davis, Davis, California, USA
  1. Correspondence to Dr Sonia Singh, Department of Paediatrics, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia; singhsd{at}


Objective To evaluate the cost-effectiveness of planned observation on cranial CT use in children with minor head trauma.

Design Planned secondary analysis of a multicentre prospective observation study.

Setting Australia and New Zealand.

Patients An analytic cohort of 18 471 children aged <18 years with Glasgow Coma Scale scores 14–15 presenting <24 hours after blunt head trauma stratified by the Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) risk categories.

Intervention A plan for observation and immediate CT scan were documented after the initial assessment. The planned observation group included those with planned observation and no immediate plan for CT.

Main outcome measures Taking an Australian public-funded healthcare perspective, we estimated the cost-effectiveness of planned observation on the adjusted mean costs per child and CT use reduction by net benefit regression analysis using ordinary least squares with robust SEs and bootstrapping. All costs presented in 2018 euros.

Results Planned observation in 4945 (27%) children was cost-saving of €85 (95% CI −120 to −51) with 10.4% lower CT use (95% CI 9.6 to 11.2). This strategy was cost-saving for the PECARN high-risk (−€757 (95% CI −961 to −554)) and intermediate-risk (−€52 (95% CI −99 to −4.3)) categories, with 43% (95% CI 39 to 47) and 11% (95% CI 9.6 to 12.4) lower CT use, respectively. The very low-risk category incurred more cost of €86 (95% CI 67 to 104) with planned observation and 0.05% lower CT use (95% CI −0.61 to 0.71).

Conclusion Planned ED observation in selected children with minor head trauma is cost-effective for reducing CT use for the PECARN intermediate-risk and high-risk categories.

Trial registration number ACTRN12614000463673.

  • health care economics and organizations
  • health services research
  • paediatric emergency medicine

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  • Contributors SS conceived the study, interpreted the data, and wrote the initial draft of the article. JAC, MB, SD and FEB obtained the data. SH and FEB had full access to all the data in the study. SH analysed the data. SS and SH supervised the data analysis, contributed to the interpretation of the data and revised the article critically. DKN, JAC, MB, SD, JH, NK and FEB interpreted the data, provided supervision, revised the paper critically. All authors revised the paper critically and approved the final manuscript as submitted. SS acts as guarantor and accepts full responsibility for the finished work and the conduct of the study, had access to the data, and controlled the decision to publish.

  • Funding The study was funded by grants from the National Health and Medical Research Council (project grant GNT1046727, Centre of Research Excellence for Pediatric Emergency Medicine GNT1058560), Canberra, Australia; the Murdoch Children's Research Institute, Melbourne, Australia; the Emergency Medicine Foundation (EMPJ-11162), Brisbane, Australia; Perpetual Philanthropic Services (2012/1140), Australia; Auckland Medical Research Foundation (No. 3112011) and the A+ Trust (Auckland District Health Board), Auckland, New Zealand; WA Health Targeted Research Funds 2013, Perth, Australia; the Townsville Hospital and Health Service Private Practice Research and Education Trust Fund, Townsville, Australia; and supported by the Victorian Government's Infrastructure Support Program, Melbourne, Australia. SS is supported by the Australian Government Research Training Program and a PREDICT CRE Research Higher Degree scholarship. FEB's time was partly funded by a grant from the Royal Children's Hospital Foundation and the Melbourne Campus Clinician Scientist Fellowship, Melbourne, Australia, and an NHMRC Practitioner Fellowship, Canberra, Australia. SRD's time was partly funded by the Health Research Council of New Zealand (HRC13/556).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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