Using a decision aid in the emergency room to help parents of children with head trauma understand options for diagnosing brain injury
Compared with the UC arm, parents of children cared for by clinicians randomized to the DA had greater knowledge of their child's risk for ciTBI and the available diagnostic options (questions correct out of 10: 6.20 DA vs 5.26 UC; mean difference [MD] = 0.95; 95% CI, 0.60-1.30), were more invo...
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| Format: | eBook |
| Language: | English |
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[Washington, D.C.]
Patient-Centered Outcomes Research Institute (PCORI)
2018, [2018]
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| Series: | Final research report
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| Online Access: | |
| Collection: | National Center for Biotechnology Information - Collection details see MPG.ReNa |
| Summary: | Compared with the UC arm, parents of children cared for by clinicians randomized to the DA had greater knowledge of their child's risk for ciTBI and the available diagnostic options (questions correct out of 10: 6.20 DA vs 5.26 UC; mean difference [MD] = 0.95; 95% CI, 0.60-1.30), were more involved in the decision (observing patient involvement scores: 25.0 [8.5] DA vs 13.3 [6.5] UC; MD = 11.7, 9.6 to 13.9), were more satisfied with their choice ("strongly satisfied": 51.5% DA vs 43.9% UC; odds ratio, 1.4, 95% CI, 0.1-1.9), and reported less decisional conflict related to feeling uninformed (decisional conflict scale: 14.8 DA vs 19.2 UC; MD = −4.9; 95% CI, −7.3 to −2.4). Parents cared for by DA clinicians also had greater trust in their physician (trust in physician scale: 91.5 [11.9] DA vs 89.3 [13.7] UC; MD = 2.3; 95% CI, 0.4-4.1). BACKGROUND: The Pediatric Emergency Care Applied Research Network (PECARN) prediction rules risk-stratify children who experience blunt head trauma into those at low, intermediate, and high risk for clinically important traumatic brain injury (ciTBI). The rules recommend observation or cranial computed tomography (CT) in children at intermediate (0.9%) risk of ciTBI but provide little guidance regarding how to engage parents in the decision of cranial CT or home observation. OBJECTIVES: We aimed to refine a shared decision-making intervention, Head CT Choice, and to test if the decision aid (DA) improves validated patient-centered outcome measures and safely decreases health care utilization. METHODS: We conducted a pragmatic multicenter randomized controlled trial in 7 emergency departments (EDs) across the United States. Clinicians and parents caring for children less than 18 years of age with 1 or 2 PECARN risk factors for ciTBI were eligible. We assigned clinicians randomly (1:1) to DA or to usual care (UC) for the duration of the study. The primary outcome, selected by parent and caregiver representatives, was parent knowledge regarding their child's risk of ciTBI and the available diagnostic options. Secondary outcomes were parent involvement in the decision, satisfaction, decisional conflict related to feeling uninformed regarding the management options, the proportion of patients who had a cranial CT during the ED visit, and health care utilization and safety (missed ciTBI) at 7 days. RESULTS: We enrolled 172 emergency clinicians caring for 971 (493 DA, 478 UC) children with head trauma. Although there was no difference in the ED rate of cranial CT between study arms (22.1% DA vs 24.3% UC; odds ratio, 0.80; 95% CI, 0.51-1.26), DA patients had a lower rate of imaging (mean number of imaging tests, 0.65 DA vs 0.88 UC; MD = −0.23; 95% CI, −0.35 to −0.11) and blood testing (mean number of tests, 0.41 DA vs 0.70 UC; MD = −0.29; 95% CI, −0.40 to −0.16) within 7 days of ED discharge. There were no detected cases of missed ciTBI. CONCLUSIONS: Use of a DA in parents of children at moderate risk for ciTBI safely increased parental knowledge, engagement, and satisfaction and decreased decisional conflict. There was no difference in ED CT use but lower health care utilization in the intervention arm at 7 days (a secondary outcome). Overall, the DA safely improved care with less utilization. LIMITATIONS AND SUBPOPULATION CONSIDERATIONS: The DA was tested only in parents of children at moderate risk of ciTBI, and the findings apply only to this population. Use of the DA had similar effects across all parent subgroups |
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| Physical Description: | 1 PDF file (72 pages) |