Background: Nontraumatic headache is a frequent complaint in the emergency department (ED). Cranial computed tomography (CT) is a widely available test for the diagnostic work-up, despite the risk of exposure to ionizing radiation. Objectives: We sought to develop and evaluate a cranial CT request computerized decision support system (CDSS) for adults with their first presentation of unusual severe nontraumatic headache in the ED. Methods: Electronic database searches identified clinical decision and prediction rules and studies delineating risk factors in nontraumatic headache. A long list of risk factors extracted from these articles was reduced by a 30-member multidisciplinary expert panel (radiologists, emergency physicians, methodologists), using a 90% agreement threshold. This shortlist was used to develop the algorithm for the cranial CT request CDSS, which was implemented in March 2016. Impact evaluation compared CT scan frequency and diagnostic yield of pathologic findings before (March–August 2015) and after (March–August 2016) implementation. Results: From the 10 selected studies, 10 risk factors were shortlisted to activate a request for cranial CT. Before implementation, 377 cranial CTs were ordered (15.3% of 2469 CT scans) compared with 244 after (9.5% of 2561 CT scans; pre–post difference 5.74%; 95% confidence interval [CI] 3.92–7.56%; p < 0.001), corresponding to a 37.6% relative reduction in the test ordering rate (95% CI 25.7–49.5%; p < 0.001). Despite the reduction in cranial CT scans, we did not observe an increase in pathological findings after introducing the decision support system (70 cases before [18.5%] vs. 35 cases after [14.3%]; pre–post difference −4.0% [95% CI −10.0 to 1.6%]; p = 0.170). Conclusion: In nontraumatic headache among adults seen in the ED, CDSS decreased the cranial CT request rate but the diagnostic yield did not improve.
Bibliographical noteFunding Information:
Supported by research grants PI13/00896 and PI13/01183 (Improving the adequacy of imaging requests with ionizing radiation [CT and Rx] in the Emergency Department, MAPAC-Image Project II) from the Instituto de Salud Carlos III , Ministerio de Ciencia e Innovación , Spain, and the European Regional Development Fund , European Union, “A way to make Europe”.
Supported by research grants PI13/00896 and PI13/01183 (Improving the adequacy of imaging requests with ionizing radiation [CT and Rx] in the Emergency Department, MAPAC-Image Project II) from the Instituto de Salud Carlos III, Ministerio de Ciencia e Innovaci?n, Spain, and the European Regional Development Fund, European Union, ?A way to make Europe?. Project File Number PI16/00558 that belongs to the State Research Plan Oriented to the Challenges of the Society within the framework of the State Plan for Scientific and Technical Research and Innovation 2013-2016, to ISCIII as a financing entity and co-financed with Feder Funds. MAPAC-Imagen Working Group: Mar?a Eugenia Cobo Reinoso, Mar?a Nieves Plana Farras, In?s Pechorrom?n de las Heras, Olga Mar?a Sanz de Le?n, Santiago Resano Pardo, Javier Bl?zquez S?nchez, Milagros Mart? de Gracia, Inmaculada Pinilla Fern?ndez, A?rea D?ez Tasc?n, Manuel Quintana D?az, Rosa Capilla Pueyo, Angel Aguado Torquero, Joaquin Moran Marsili, Lorena Rodr?guez Gij?n, Diego Garrido Alonso, Alfonso Martin Diaz, Lucia Fern?ndez, Alberto Borobia, Gonzalo Garz?n Moll, Daniel Bernabeu Taboada, Mar?a Jos? Sim?n Merlo, Magdalena Carreras Aja, Rafael Villoria Alonso, Josu Mendiola Arza, Jennifer Barredo Parra, Leire Atilano Santos, Gotzon Iglesias Hidalgo, Ana Rosa Gil Martin, Ver?nica Garc?a de Pereda de Blas, Aitor Garc?a de Vicu?a Mel?ndez, Silvia Carbajo Azabal, Ana Santorcuato Bilbao, Marta Estaella Bellart, Sara de Benito Sobrado, Eunate Arana-Arri.
© 2019 Elsevier Inc.
- cranial CT
- emergency department
- nontraumatic headache
ASJC Scopus subject areas
- Emergency Medicine