Identification of Abusive Head Trauma in High-Risk Infants: A Cost-Effectiveness Analysis

• Published in: The Journal of pediatrics 2020-12, Vol.227, p.176-183.e3
• Main Authors: Noorbakhsh, Kathleen A., Berger, Rachel P., Smith, Kenneth J.
• Format: Article
• Language: English
• Subjects: child abuse; Child Abuse - diagnosis; Child Abuse - statistics & numerical data; Cost-Benefit Analysis; Craniocerebral Trauma - diagnosis; Craniocerebral Trauma - epidemiology; diagnostic imaging; economic analysis; Emergency Service, Hospital; Humans; Infant; Models, Theoretical; Risk Assessment; traumatic brain injury
• ISSN: 0022-3476; 1097-6833
• DOI: 10.1016/j.jpeds.2020.06.003

To evaluate the cost-effectiveness of abusive head trauma detection strategies in emergency department settings with and without rapid magnetic resonance imaging (rMRI) availability. A Markov decision model estimated outcomes in well-appearing infants with high-risk chief complaints. In an emergency department without rMRI, we considered 3 strategies: clinical judgment, universal head computed tomography (CT) scan, or the Pittsburgh Infant Brain Injury Score (PIBIS) with a CT scan. In an emergency department with rMRI for brain availability, we considered additional strategies: universal rMRI, universal rMRI with a CT scan, PIBIS with rMRI, and PIBIS with rMRI followed by a CT scan. Correct diagnosis eliminated future risk; missed abusive head trauma led to reinjury risk with associated poor outcomes. Cohorts were followed for 1 year from a healthcare perspective. One-way and probabilistic sensitivity analyses were performed. The main outcomes evaluated in this study were abusive head trauma correctly identified and incremental cost per quality-adjusted life-year. Without rMRI availability, PIBIS followed by a CT scan was the most cost-effective strategy. Results were sensitive to variation of CT scan-induced cancer parameters and abusive head trauma prevalence. When rMRI was available, universal rMRI followed by a confirmatory CT scan cost $25 791 to gain 1 additional quality-adjusted life-year compared with PIBIS followed by rMRI with a confirmatory CT scan. In both models, clinical judgement was less effective than alternative strategies. By applying CT scans to a more targeted population, PIBIS decreases radiation exposure and is more effective for the identification of abusive head trauma compared with clinical judgment. When rMRI is available, universal rMRI with a CT scan is more effective than PIBIS and is economically favorable.