In 2012, the American College of Emergency Physicians (ACEP), like other specialty societies, began a conversation with its members to develop five “Choosing Wisely®” recommendations. One of their first recommendations was to avoid low-value Computed Tomography (CT) scans of the head in patients with minor head injury. ACEP’s multistep process began with input from its Cost-Effective Task Force (Task Force), which administered a survey to ACEP members asking for strategies to “reduce costs and improve value in Emergency Medicine.” The Task Force determined that the evidence was clear; patients with minor head injury that are low risk for intracranial bleeding or skull fracture by decision rules would benefit from a conversation with their clinician on the utility of a head CT.1
After the Choosing Wisely Campaign launched, a series of studies published from 2017-2021 evaluated its impact. One of the first published evaluations was a retrospective cohort study at an academic Level-1 Trauma Center. The study included 489 patients with minor head injury and assessed whether ED clinicians appropriately applied the Choosing Wisely criteria. The NEXUS II clinical decision rule, which uses a series of clinical criteria to risk stratify the severity of a patient’s head injury, was used as a benchmark.2 Clinicians captured the clinical criteria for the decision rule well; however, they still obtained “non-indicated” CTs in 23.1% of patients.3
Emergency Clinicians are quick to identify the goals of Choosing Wisely; however, low-value CT scans of the head continue to be ordered. Surveys cite Emergency Clinicians’ “concern for serious diagnosis” and “patient or family expectations” as reasons why patients with minor head injury continue to receive low-value head CT scans.1 Given that 3.6% of all ED visits present for head injury, there is significant opportunity to improve the value of care for ED patients. Head CTs that expose patients to ionizing radiation and can increase a patient's lifetime risk of cancer should not be performed when clinicians can safely risk stratify a patient without the expense of a potentially harmful test.1
A large survey of Emergency Clinicians began to unpack the clinician response to the Choosing Wisely campaign. In their discussion, the authors state “some clinicians may have a good understanding of the evidence base, but choose to deviate from guidelines and rely on patient clinical factors or “gestalt,” as decision rules are imperfect.”4
Although Emergency Clinicians understand and agree with the sentiment of the Choosing Wisely campaign, they fear missing a serious diagnosis and want to fulfill the expectations of their patient and the patient’s family during the ED visit. When it comes to possible life-threatening diagnosis, such as those in head injury, Emergency Clinicians need an objective test they can trust.
Read Next: Objective Decision Support to Reduce Low Clinical Value Head CTs
1. Avoid computed tomography (CT) scans of the head in emergency department patients with minor head injury who are at low risk based on validated decision (Choosing Wisely) rules.https://www.choosingwisely.org/clinician-lists/american-college-emergency-physicians-ct-scans-of-head-for-emergency-department-patients-with-minor-head-injury/ (accessed Sept 30, 2022).
2. DeAngelis, J., Lou, V., Li, T., Tran, H., Bremjit, P., McCann, M., ... & Jones, C. M. (2017). Head CT for minor head injury presenting to the emergency department in the era of choosing wisely. Western Journal of Emergency Medicine, 18(5), 821.
3. Quality ID #415: Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older (CMS) https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_415_MIPSCQM.pdf (accessed October 24, 2022).
4. Lin, M. P., Nguyen, T., Probst, M. A., Richardson, L. D., & Schuur, J. D. (2017). Emergency physician knowledge, attitudes, and behavior regarding ACEP's choosing wisely recommendations: a survey study. Academic Emergency Medicine, 24(6), 668-675.
