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1 Overuse CT Overuse for Mild Traumatic Brain Injury Edward R. Melnick, MD; Christopher M. Szlezak, MD; Suzanne K. Bentley, MD; James D. Dziura, PhD; Simon Kotlyar, MD, MSc; Lori A. Post, PhD The United States and its health care system are in a financial crisis. According to a recent report by the Institute of Medicine, up to $750 billion of health care spending per year yields no patient benefits. 1 Overuse, the provision of medical services with no benefit or for which harms outweigh benefits, 2(p.171) accounts for a large part of this waste. Although computed tomography (CT) has greatly improved diagnostic ability, it exposes patients to ionizing radiation and subsequently a risk of cancer. 3 The use of CT is growing at an alarming rate, with nearly 70 million scans performed annually in the United States. 4 8 Although the use of CT scans for injuryrelated emergency department (ED) visits has tripled in 10 years, there has been no increase in the diagnosis of life-threatening conditions or admission rates. 9 More than 1.3 million patients are treated and released from EDs annually for mild traumatic brain injury (MTBI) in the United States. 10 Minor head injury is defined as blunt trauma to the head and a history of loss of consciousness, amnesia, or disorientation and a Glasgow Coma Scale (GCS) score of Most minor head injuries are mild, but in a small proportion of patients clinical deterioration occurs. 12 In patients with clinically important brain injury, CT imaging yields a quick and accurate diagnosis such that neurosurgical intervention can potentially prevent deleterious outcomes from intracranial hematoma. 11 Overuse of CT adds to health care costs and can subject patients to unnecessary cancer risk. 3,6 The radiation dose of a routine head CT is approximately 2 millisieverts. 6 The risk of cancer associated with this ionizing radiation dose is age and gender specific, with a rough order of magnitude of one radiation-induced cancer per 10,000 CTs performed in adult patients. 6 Current practice does not mandate that the provider and patient discuss the risks associated with CT scans. 13 To prevent overuse of CT and to differentiate MTBI from clinically important brain injury, multiple evidence-based guidelines exist to direct appropriate use of CT four high-quality guidelines that are frequently used in practice include the Canadian Article-at-a-Glance Background: Multiple, validated, evidence-based guidelines exist to inform the appropriate use of computed tomography (CT) to differentiate mild traumatic brain injury (MTBI) from clinically important brain injury and to prevent the overuse of CT. Yet, CT use is growing rapidly, potentially exposing patients to unnecessary ionizing radiation risk and costs. A study was conducted to quantify the overuse of CT in MTBI on the basis of current guideline recommendations. Methods: A retrospective analysis of secondary data from a prospective observational study was undertaken at an urban, Level I emergency department (ED) with more than 90,000 visits per year. For adult patients with minor head injury receiving CT imaging at the discretion of the treating physician, the proportion of cases meeting criteria for CT on the basis of the Canadian CT Head Rule (CCHR), American College of Emergency Physicians (ACEP) Clinical Policy, New Orleans Criteria (NOC), and National Institute for Health and Clinical Excellence (NICE) guidelines was reported. Results: All 346 patients enrolled in the original study were included in the analysis. The proportion of cases meeting criteria for CT for each of the guidelines was: CCHR 64.7% (95% confidence interval [CI], ), ACEP 74.3% (95% CI, ), NICE 86.7% (95% CI, ), and NOC 90.5% (95% CI, ). The odds ratio of the guidelines for predicting positive head CT findings were also reported. Discussion: Some 10% 35% of CTs obtained in the ED for MTBI were not recommended according to the guidelines. Successful implementation of existing guidelines could decrease CT use in MTBI by up to 35%, leading to a significant reduction in radiation-induced cancers and health care costs. 483

2 CT Head Rule (CCHR), American College of Emergency Physicians (ACEP) Clinical Policy, New Orleans Criteria (NOC), and National Institute for Health and Clinical Excellence (NICE) guidelines (Figure 1, page 485) The guidelines overlap, reflecting their derivation from some of the same large data sets. 15,17,19 The sensitivity and specificity of the CCHR and NOC have been previously validated. 15,17,19,20 Implementation of the CCHR in the Netherlands in would have the potential to reduce 37% of CT scans for patients with minor head injury. 21 Failed implementation of guidelines on appropriate imaging in MTBI has led authors to conclude that CT imaging is now considered the standard of care for minor head injury in the ED. 22,23 The CCHR is a clinical decision rule that was developed using a rigorous, evidence-based derivation and validation process and has been externally validated to be 100% sensitive in EDs in the United States and Canada. 15,19,20,24 A recent prospective multicenter cluster-randomized trial to implement a similar prediction rule the Canadian C-Spine Rule led to a significant decrease in imaging without injuries being missed. 25 When the CCHR was implemented at the same centers with many of the same patients, however, CT imaging rates did not decrease. 15,19,23 In fact, imaging rates were 74% 76% after guideline implementation, compared with 63% 68% without it. 23 These rates were more than double the rate of use found 12 years earlier in the same region. 26 Implementation of the ACEP clinical practice guidelines, which were jointly developed with the Centers for Disease Control and Prevention, has met with mixed results A national survey of 1,003 emergency physicians and residents found that only 25% were aware of the guidelines. Further, only 75% recognized the clinically important indicators for the appropriate use of CT. 22 This study was conducted to quantify the overuse of CT in MTBI in the ED on the basis of current guideline recommendations. We hypothesized that providers are not obtaining imaging consistent with guidelines, leading to unnecessary CTs, cancer risk, and cost. Methods STUDY DESIGN, SETTING, AND SUBJECTS This was a retrospective analysis of secondary data from a prospective observational study that addressed the diagnostic utility of the S100B biomarker in predicting significant brain injury. 31 The original data were previously collected and de-identified for the study, which used a convenience sample of patients 18 years of age or older who presented with minor head injury to an urban Level I ED (with more than 90,000 visits per year) from March 2006 through April For the purposes of the original study, minor head injury was defined as blunt trauma to the head with a GCS of 13 15, with or without loss of consciousness, and a nonfocal neurologic examination. Patients presenting within six hours of injury and undergoing CT for evaluation of minor head injury were eligible for enrollment. Minor head injury patients not undergoing CT were not enrolled. Because the goal of the original study was to compare the S100B biomarker s diagnostic utility with that of CT, the decision to perform CT was at the discretion of the treating physician and was a prerequisite for enrollment. This inclusion criterion was congruent with the needs of the current study, in which the goal of the analysis was to quantify the number of unnecessary CTs performed on the basis of current guideline recommendations. Patients with concomitant trauma were eligible for enrollment. Alcohol- and drug-intoxicated patients were also eligible for enrollment if time of injury was known. Exclusion criteria included patients with major trauma (including hemodynamic instability, airway or cervical spine/neurologic compromise, penetrating trauma to trunk/abdomen, fall from height greater than 12 feet, ejection from vehicle, or significant trauma above and below diaphragm), non-english-speaking patients, altered mental status of unclear etiology, and known previous intracranial pathology. Informed consent was obtained from patients. The original study was approved by the Yale University Human Investigations Committee, which deemed the current study Institutional Review Board exempt. DATA COLLECTION AND ANALYSIS Patient enrollment is described in detail in the original study. 31 Head CT results were considered positive if any of the following outcomes were identified by the attending radiologist: subarachnoid hemorrhage, epidural hemorrhage, subdural hemorrhage, intraparenchymal hemorrhage, diffuse brain edema, diffuse axonal injury, or skull fracture. The original data set included details regarding patient demographics and clinical parameters, such as injury mechanism, drug/medication use, signs, and symptoms. These demographics and clinical parameters were stored in a de-identified database using Statistical Package for the Social Sciences (SPSS; SPSS Inc., Chicago). The data set was converted into a database and queried by one of the investigators [C.M.S.] to determine whether each case met criteria for head CT on the basis of the CCHR (combined mediumand high-risk criteria), ACEP Clinical Policy, NOC, and NICE guidelines (Figure 1) SPSS was then used to calculate the proportion of cases (with a 95% confidence interval [CI]) meeting criteria for CT on the basis of each guideline. SPSS was then 484

3 Indications for Computed Tomography (CT) in Patients Presenting to the Emergency Department with Minor Head Injuries from the Canadian CT Head Rule, ACEP Recommendations, National Institute for Health and Clinical Excellence (NICE) Recommendations, and New Orleans Criteria Canadian CT Head Rule CT head scan is only required for patients with minor head injuries with any one of the following: High risk (for neurological intervention) GCS score <15 at 2 h after injury Suspected open or depressed skull fracture Any sign of basal skull fracture (hemotympanum, raccoon eyes, cerebrospinal fluid otorrhoea/ rhinorrhoea, Battle s sign) Vomiting 2 episodes Age 65 years Medium risk (for brain injury on CT) Amnesia before impact > 30 min Dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height > 3 feet or 5 stairs) Minor head injury is defined as witnessed loss of consciousness, definite amnesia, or witnessed disorientation in patients with a GCS score of Not applicable if warfarin use or bleeding disorder or patient suffered a seizure before arrival to the ED. ACEP Clinical Policy Recommendations Which patients with mild TBI should have a noncontrast head CT scan in the ED? Level A recommendations. A noncontrast head CT is indicated in head trauma patients with loss of consciousness or posttraumatic amnesia only if one or more of the following is present: headache, vomiting, age greater than 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicle, posttraumatic seizure, GCS score less than 15, focal neurologic deficit, or coagulopathy. Level B recommendations. A noncontrast head CT should be considered in head trauma patients with no loss of consciousness or posttraumatic amnesia if there is a focal neurologic deficit, vomiting, severe headache, age 65 years or greater, physical signs of a basilar skull fracture, GCS score less than 15, coagulopathy, or a dangerous mechanism of injury.* * Dangerous mechanism of injury includes ejection from a motor vehicle, a pedestrian struck, and a fall from a height of more than 3 feet or 5 stairs. NICE Head Injury Guideline Recommendations Request CT scan immediately if any of the following are present: GCS score < 15 at 2 h after injury Suspected open or depressed skull fracture Sign of fracture at skull base (hemotympanum, panda eyes, cerebrospinal fluid from ears or nose, Battle s sign) Posttraumatic seizure Focal neurological deficit > 1 episode of vomiting Amnesia of events > 30 minutes before impact Request CT scan immediately if loss of consciousness or any amnesia and any of the following are present: Age 65 years Coagulopathy (history of bleeding, clotting disorder, current treatment with warfarin) Dangerous mechanism of injury (pedestrian or cyclist struck by motor vehicle, occupant ejected from motor vehicle, fall from height > 1 m or 5 stairs) New Orleans Criteria In patients with GCS of 15, loss of consciousness, and normal findings on a brief neurologic exam, indications for CT scan are as follows: Headache Vomiting Seizure Intoxication Short-term memory deficit Age > 60 years Injury above the clavicles Figure 1. The four high-quality guidelines, frequently used in practice and used in this study, are shown. ACEP, American College of Emergency Physicians; GCS, Glasgow Coma Scale; ED, emergency department; TBI, traumatic brain injury. used to estimate the odds ratio (OR) of a positive CT head finding in those rated appropriate by each guideline recommendation, compared with those rated inappropriate with 95% CIs for each of the four guidelines of interest. Indications for CT in patients presenting to the ED with minor head injuries on the basis of the CCHR (combined medium- and high-risk criteria), ACEP Clinical Policy (either level A or B recommendations), NICE guidelines, and NOC are provided in Figure 1. CT was considered inappropriate (that is, overused or guidelinenoncompliant) if the subject received a CT scan but did not have an indication for CT on the basis of each individual guideline. 485

4 Results STUDY DEMOGRAPHICS During the original study period from March 2006 through April 2007, 2,040 patients underwent CT head examination for evaluation of trauma. From this sample, 833 patients (41%) were eligible for enrollment as defined by the inclusion/exclusion criteria. Of those patients eligible, 346 (42%) were enrolled. Some 215 (62%) of the patients were men, and the mean age was 48 years. There were no significant differences in demographics between patients with and without radiographic evidence of head injury. The full details of demographics, enrollment, and mechanism and details of injury are available in the original study. 31 Of the 22 patients with radiographic evidence of head injury, there were 9 intraparenchymal hemorrhages, 7 subarachnoid bleeds, 6 subdural hematomas, and 5 skull fractures. No patients required neurosurgical intervention; however, one patient did require intubation. 31 GUIDELINE COMPLIANCE Figure 2 (right) demonstrates compliance with these guidelines in the 346 patients studied here. The proportion of these cases meeting criteria for CT for each of the guidelines was: CCHR (combined medium- and high-risk criteria) 64.7% (95% CI, ), ACEP 74.3% (95% CI, ), NICE 86.7% (95% CI, ), and NOC 90.5% (95% CI, ). ODDS RATIOS The data suggest that the odds of having a positive CT head finding in those rated appropriate by the following guideline recommendation compared with those rated inappropriate were: CCHR 2.17 (95% CI, ), ACEP Clinical Policy 8.65 (95% CI, ), NICE 1.74 (95% CI, ), and NOC 1.17 (95% CI, ). LIMITATIONS As a retrospective review of prospectively collected data, our analysis was limited by the data collected in the original study. With respect to determining guideline compliance, certain data points were not collected for the original database, limiting our ability to determine accurate compliance data. To account for this limitation, guideline compliance was overestimated. For example, vomiting is a variable in the ACEP, NOC, and CCHR guidelines, while the latter requires greater than two episodes of vomiting. The number of episodes of vomiting was not recorded, so any patient with recorded vomiting who received a CT scan was considered to be in compliance with this guideline. This was Percentage Compliance with the Four Guideline Recommendations (CCHR, ACEP, NICE, and NOC) Figure 2. The proportion of 346 cases meeting criteria for computed tomography (CT) for the four guidelines varied from 64.7% to 90.5%. CCHR, Canadian CT Head Rule; ACEP, American College of Emergency Physicians; NICE, National Institute for Health and Clinical Excellence; NOC, New Orleans Criteria. also a limitation for the variable dangerous mechanism, which includes falls of greater than three feet or five stairs. The original data set did not specify height of fall, so all patients whose mechanism was fall and who received a CT were considered to be in compliance. Similarly, presence of any headache was presumed to be a severe headache for the ACEP Clinical Policy. Similarly, overuse may be underestimated here because the original NOC and CCHR inclusion criteria for minor head injury required patients to experience loss of consciousness or amnesia. 15,17 However, the current standard of care in the United States includes application of these rules to all minor head injuries regardless of loss of consciousness and amnesia, as Kotlyar et al. did in the study data set that we are using for secondary data. 31 In addition, the original data set did not include patients who did not receive a CT. Therefore, reporting a false-negative rate per guideline is beyond the scope of this project. Another potential limitation is application of the ACEP Clinical Policy on MTBI during this study period. The data collected for this analysis were from ; however, the ACEP Clinical Policy was not updated to its current recommendations until Survey data collected at the 2008 ACEP National Conference demonstrate that providers were less aware of either the 2002 or 2008 guidelines because of traditional dissemination strategies. 22 Given that much of the ACEP guideline content comes from earlier data and initial recommendations 486

5 published in 2002, ACEP guideline compliance is still relevant in this study investigating potential reduction of CT use. Discussion Clinical practice guidelines are not perfect. They apply to populations, not individual patients. The art of medicine allows physicians to identify exceptions to the rule. However, successful implementation of trustworthy guidelines promises to help cut wasteful defensiveness and should improve quality, cost, and patient outcomes. 32 Analysis of these guidelines on the basis of our data shows the highest ORs for the ACEP guidelines, followed by CCHR, NICE and NOC. Our data suggest that 10% 35% of CTs obtained in the ED for minor head injury are not guideline-compliant; that is, with a range of overuse of approximately 10% for NOC to 35% for CCHR. Successful implementation of these guidelines could potentially reduce CT use in minor head injury by up to 35%. This figure is supported by recent overuse studies, including the 2012 Institute of Medicine report, which stated that one third of health care expenditures do not improve health, 1 and a recent study on pulmonary embolism evaluation demonstrating a 32% avoidable-imaging rate. 33 Cost analyses for imaging are difficult to perform because of regional variance, insurance policies and payment structures, and overhead. A previous cost-effectiveness analysis found that performing CT selectively according to the CCHR could lead to $120 million of savings annually in the United States. 34 Our data and roughly extrapolating a 35% reduction in CT use for minor head injury at a national level suggest savings of up to $394 million annually and the prevention of approximately 36 radiationinduced cancers not to mention likely improvements in ED length of stay for these patients. (See Sidebar 1, right, for calculations based on an estimated average cost of $1,100/ CT. 10,23,31,34,35 ). Clearly, containing costs associated with CT overuse in MTBI is aligned with the priority of cost containment delineated in the Affordable Care Act (ACA). Specifically, the ACA includes a provision that adjusts payments to physicians on the basis of their adherence to appropriateness criteria in ordering diagnostic imaging. 36 As evidence-based practice continues to become the gold standard in medicine, continual dissemination of new research findings makes it challenging for any practitioner to stay abreast of the newest guidelines and implement them in practice. Publication groups such as the Cochrane Collaboration and national organizations such as the ACEP develop guidelines on the basis of collaborative findings from multiple studies and sites to establish evidence-based standards of practice. Evidence-based Sidebar 1. Predicted Annual Avoidable Risk and Cost with Successful Implementation of the Canadian CT Head Rule (CCHR) in the United States* million emergency department patients are treated and released with head injury. Approximately 75% of patients receive CTs 1,023,750 CTs are performed. 358,312 scans are unnecessary (on the basis of 35% noncompliance with CCHR). Roughly 36 preventable radiation-induced cancers annually (assuming one cancer for every 10,000 head CTs) $394 million savings annually * CT, computed tomography. medicine (EBM) aims to combine external evidence derived from credible research with clinical expertise to develop clinical practice guidelines that can be used to highlight practices that systematically result in improved patient outcomes. 37 Although EBM has been widely recognized as an important component of health care, implementation of new guidelines and protocols continues to be a challenge. 38 Multiple studies show poor adherence to standard-of-care guidelines, such as those evaluated in this study. 39,40 Two of the most notable obstacles to physicians guideline compliance is the basic lack of awareness of the existence of the guidelines and a lack of successful implementation Bentley et al. evaluated emergency physicians awareness of the ACEP MTBI guidelines, as well as their familiarity with specific guidelines, via questions directly related to the individual recommendations. The survey asked respondents about their awareness of the guidelines and/or revisions to determine if their awareness had led them to change their clinical practice. Only 51.5% reported that awareness of the guidelines had led to a change in clinical practice. This illustrates the problem: Even when clinicians are aware of the guidelines, they are not necessarily familiar with them or implementing them in their clinical practice. 22 Studies analyzing successful guideline adherence have focused on two aspects: Characteristics of successful guidelines and successful implementation strategies. Not surprisingly, research shows that guidelines that are less complex, include concrete definitions, and are easy to follow have high rates of compliance, as do those with strong supporting evidence. 30,42,45 Thus, the overall recommendation for guideline development is a logical one: Guidelines should be easy to understand and strongly supported by clear evidence and should fit as easily as possible into established practice patterns. 487

6 Although passive dissemination of information may be marginally helpful in raising awareness, an active approach is more effective. 42,46 Bates et al. examined the effectiveness of computerized clinical decision support that includes passive and active referential information as well as reminders, alerts, and guidelines delivered to clinicians in real time to achieve large gains in performance, narrow gaps between knowledge and practice, and improve safety. 47(p. 524) Such computerized programs with discreet algorithms may help attenuate the problem of lack of awareness. Melnick et al. examined the feasibility of translating guideline recommendations into real-time computerized clinical decision support systems to increase adherence to ACEP guidelines such as the MTBI guidelines, and similar systems could help address the aforementioned barriers to guideline implementation and improve clinical decision making at the point of care. 30 A large part of health care resource overuse comes from medical legal concerns and the practice of defensive medicine, namely assurance behavior providing tests or services of marginal or no medical value due to physicians fear of being sued. 1 Assurance behavior is more prevalent in the ED than any other clinical realm. 9 Imaging is the fastest growing part of health care spending in the United States, increasing twice as fast as total health care costs. 32 In fact, CT imaging rates for head injury in the ED are lowest in states that have passed tort reform laws. 35 This suggests that medical legal concerns are a significant factor influencing overuse of CT in MTBI. Another barrier to guideline implementation success may be the fact that ED patients are more confident with their medical evaluation when CT imaging is provided. 48 Many patients perceive imaging as more objective and safer than an assessment by a provider they just met. Moreover, the public s perception of the risk associated with mild head injury may have been skewed by the well-publicized death of actress Natasha Richardson in Risk-averse providers may, therefore, choose to ignore guideline recommendations and obtain unnecessary CTs to make a quick and accurate diagnosis and placate patients concerns. 51,52 IMPLICATIONS FOR PRACTICE AND RESEARCH Because they have not yet been studied, patients expectations and preferences for imaging are not well understood. 48 Patients often have unrealistic expectations of benefits and harms, providers are poor judges of patient preferences and values, and these factors contribute to overuse of resources that informed patients may not value. 14,32,42,53,54 Perhaps this is because traditional guidelines and decision rules are geared toward physician decision making without considering patients preferences or the need to educate patients that more care is not always better. Shared decision making could overcome the limitations of conventional approaches to translation of evidence-based medicine by addressing patients and providers interests. 8,13 For example, for ED patients with chest pain, presenting a decision aid that includes their quantitative pretest probability of acute coronary syndrome decreased imaging rates by 11%, decreased hospital admission rates by 6%, and improved patient satisfaction by 11% without having any delayed or missed diagnoses. 55 The CCHR was rigorously derived and validated to be 100% sensitive for differentiating mild traumatic brain injury from clinically important brain injury in both Canada and the United States. 15,19,20 Yet this rule is presented to providers with undifferentiated pretest probabilities of moderate and high. The CCHR does not offer patients their pretest probability if they do not meet criteria (presumably, low risk). Deriving these pretest probabilities is a critical and necessary step to involving patients in transparent, informed decision making regarding CT imaging in minor head injury. J The authors thank Research Associate Alexei Nelayev for his invaluable assistance with data analysis and the Institutional Review Board process. Edward R. Melnick, MD, is Assistant Professor and Christopher M. Szlezak, MD, is Resident, Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut. Suzanne K. Bentley, MD, is Clinical Instructor, Department of Emergency Medicine, Mount Sinai School of Medicine, New York City. James D. Dziura, PhD, is Associate Professor; Simon Kotlyar, MD, MSc, is Assistant Professor; and Lori A. Post, PhD, is Associate Professor, Department of Emergency Medicine, Yale School of Medicine. Please address correspondence to Edward R. Melnick, edward.melnick@yale.edu. References 1. Smith, MD, et al.; Committee on the Learning Health Care System in America, Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press, Korenstein D, et al. Overuse of health care services in the United States: An understudied problem. Arch Intern Med Jan 23;172(2): Brenner DJ, Hall EJ. Computed tomography An increasing source of radiation exposure. N Engl J Med Nov 29;357(22): Broder J, Warshauer DM. Increasing utilization of computed tomography in the adult emergency department, Emerg Radiol. 2006;13(1): Boone JM, Brunberg JA. Computed tomography use in a tertiary care university hospital. J Am Coll Radiol. 2008;5(2): Smith-Bindman R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med Dec 14;169(22): Smith-Bindman R, et al. Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, JAMA Jun 13;307(22): The Joint Commission. Radiation Risks of Diagnostic Imaging. Sentinel Event Alert No. 47. Aug 24, Accessed Sep 26, Korley FK, Pham JC, Kirsch TD. Use of advanced radiology during visits to 488

7 US emergency departments for injury-related conditions, JAMA Oct 6;304(13): US Centers for Disease Control and Prevention. Traumatic Brain injury in the United States: Emergency Department Visits, Hospitalizations and Deaths Faul M, et al. Mar Accessed Sep 26, Shackford SR, et al. The clinical utility of computed tomographic scanning and neurologic examination in the management of patients with minor head injuries. J Trauma. 1992;33(3): Marshall LF, Toole BM, Bowers SA. The National Traumatic Coma Data Bank. Part 2: Patients who talk and deteriorate: Implications for treatment. J Neurosurg. 1983;59(2): Baerlocher MO, Detsky AS. Discussing radiation risks associated with CT scans with patients. JAMA Nov 17;304(19): Tavender EJ, et al. Quality and consistency of guidelines for the management of mild traumatic brain injury in the emergency department. Acad Emerg Med. 2011;18(8): Stiell IG, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet May 5;357(9266): Jagoda AS, et al. Clinical policy: Neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Ann Emerg Med. 2008;52(6): Haydel MJ, et al. Indications for computed tomography in patients with minor head injury. N Engl J Med Jul 13;343(2): National Institute for Health and Clinical Excellence. Head Injury: Triage, Assessment, Investigation and Early Management of Head Injury in Infants, Children and Adults. Sep Accessed Sep 26, /CG Stiell IG, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA Sep 28;294(12): Papa L, et al. Performance of the Canadian CT Head Rule and the New Orleans Criteria for predicting any traumatic intracranial injury on computed tomography in a United States Level I trauma center. Acad Emerg Med. 2012;19(1): Smits M, et al. External validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head injury. JAMA Sep 28;294(12): Bentley S, et al. Emergency physicians clinical practice regarding the ACEP/CDC Adult Traumatic Brain Injury Clinical Policy. Paper presented at ACEP Scientific Assembly, Boston, 2009 (Abstract). 23. Stiell IG, et al. A prospective cluster-randomized trial to implement the Canadian CT Head Rule in emergency departments. CMAJ Oct 5;182(14): Stiell IG, Wells GA. Methodologic standards for the development of clinical decision rules in emergency medicine. Ann Emerg Med. 1999;33(4): Stiell IG, et al. Implementation of the Canadian C-Spine Rule: Prospective 12 centre cluster randomised trial. BMJ Oct 29;339:b4146. doi: /bmj.b Stiell IG, et al. Variation in ED use of computed tomography for patients with minor head injury. Ann Emerg Med. 1997;30(1): Elesber AA, et al. Impact of the application of the American College of Emergency Physicians recommendations for the admission of patients with syncope on a retrospectively studied population presenting to the emergency department. Am Heart J. 2005;149(5): Lehrmann JF, et al. Knowledge translation of the American College of Emergency Physicians clinical policy on hypertension. Acad Emerg Med. 2007;14(11): Melnick ER, et al. Knowledge translation of the American College of Emergency Physicians clinical policy on syncope using computerized clinical decision support. Int J Emerg Med Jun 1;3(2): Melnick ER, et al. Delphi consensus on the feasibility of translating the ACEP clinical policies into computerized clinical decision support. Ann Emerg Med. 2010;56(4): Kotlyar S, et al. S100B Immunoassay: An assessment of diagnostic utility in minor head trauma. J Emerg Med. 2011;41(3): Bovbjerg RR, Berenson RA. Urban Institute/Robert Wood Johnson Foundation: The Value of Clinical Practice Guidelines as Malpractice Safe Harbors. Apr Accessed Sep 20, /research-publications/find-rwjf-research/2012/04/the-value-of-clinical -practiceguidelines-as-malpractice safe-h.html. 33. Venkatesh, AK, et al. Evaluation of pulmonary embolism in the emergency department and consistency with a national quality measure: Quantifying the opportunity for improvement. Arch Intern Med Jul 9;172(13): Smits M, et al. Minor head injury: CT-based strategies for management A cost-effectiveness analysis. Radiology. 2010;254(2): Smith-Bindman R, et al. Diagnostic imaging rates for head injury in the ED and states medical malpractice tort reforms. Am J Emerg Med. 2011;29(6): Kline JA, Walthall JD. Patient Protection and Affordable Care Act of 2010: Summary, analysis, and opportunities for advocacy for the academic emergency physician. Acad Emerg Med. 2010;17(7):e Elstein AS. On the origins and development of evidence-based medicine and medical decision making. Inflamm Res. 2004;53 Suppl 2:S Formoso G, Liberati A, Magrini N. Practice guidelines: Useful and participative method? Survey of Italian physicians by professional setting. Arch Intern Med Sep 10;161(16): McGlynn EA, et al. The quality of health care delivered to adults in the United States. N Engl J Med Jun 26;348(26): Pham JC, Kelen GD, Pronovost PJ. National study on the quality of emergency department care in the treatment of acute myocardial infarction and pneumonia. Acad Emerg Med. 2007;14(10): Cabana MD, et al. Why don t physicians follow clinical practice guidelines? A framework for improvement. JAMA Oct 20;282(15): Grol R, Grimshaw J. From best evidence to best practice: Effective implementation of change in patients care. Lancet Oct 11;362(9391): Glasziou P, Haynes B. The paths from research to improved health outcomes. ACP J Club. 2005;142(2):A Lang ES, Wyer PC, Haynes RB. Knowledge translation: closing the evidence-to-practice gap. Ann Emerg Med. 2007;49(3): Burgers JS, et al. Characteristics of effective clinical guidelines for general practice. Br J Gen Pract. 2003;53(486): Grimshaw JM, et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001;39(8 Suppl 2):II Bates DW, et al. Ten commandments for effective clinical decision support: Making the practice of evidence-based medicine a reality. J Am Med Inform Assoc. 2003;10(6): Baumann BM, et al. Patient perceptions of computed tomographic imaging and their understanding of radiation risk and exposure. Ann Emerg Med. 2011;58(1): ABC News. Was Richardson s Death Avoidable? Childs D, Markiar S. Mar 19, Accessed Sep 26, Mood-News/story?id= &page= New York Post. Canadacare May Have Killed Natasha. Franklin C. Mar 26, Accessed Sep 26, opedcolumnists/item_gcjdjyjibpnoxpoktu1x8l;jsessionid=25ef4e24421 A03DA751B55701AE Wears RL. Risk, radiation, and rationality. 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