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Rapid Responses: Rapid Responses published:
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What about the radiation cost?
- Sanjay P Prabhu (12 August 2006)
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Author's reply
- Anders Norlund (24 August 2006)
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Admission for minor head injury is expensive and ineffective
- Steve Goodacre (4 September 2006)
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CT for Mild Head Injury: Irradiation Issues
- Jane L Ferguson, Douglas J Ferguson (10 October 2006)
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Sanjay P Prabhu, Paediatric Radiology Fellow Royal Children's Hospital
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I was very interested in the conclusions drawn by the authors and the message being sent out about CT for mild head injury. It is a well thought out research study except for the fact that the age range being looked at was very wide. This leads to the question of what is the radiation cost in the younger patients who may have a number of mild head injuries throughout their childhood and teen years. I would like to point out that in the paediatric age group, I would be very worried about randomising a group of patients between CT and observation particularly in cases where there is no clinical need for a scan. The long term radiation induced effects must be kept in mind when this study is quoted in the media for reference by the general public and the non-radiologist readers. Indeed most of the clinically significant cases were in the elderly population (>60 years)and yet the abstract suggests that the conclusions are applicable in patients aged >6years. Did the ethics committee reviewing this project have any reservations about the radiation risk in the young patient or did not consider this to be significant? Competing interests: Paediatric Radiologist |
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Anders Norlund, Health Economist SBU, Stockholm, Sweden
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Thank you for your interesting comments. The aim of this study was to investigate acute management of mild head injury from a medical and an economical point of view. Included patients from six years of age were followed from the first visit at an emergency ward to 3 months after that visit. Thus, the longitudinal follow up was limited. The epidemiological, longitudinal study with economic applications that Dr Prabhu suggests, a study lasting for several years, is also highly interesting, but concerns another kind of study design than ours. Since the increased lifetime mortality risk due to cancer from radiation from a number of CT´s is low, such a study needs to be very large to be conclusive [1]. Including children from birth would also probably find some highly skewed data on costs, since CT’s of very small children may require interventions of anaesthesia and supplementary surveillance, thus not relevant for ordinary CT’s like those included in the present study. As concerns the increased risk of radiation from a single CT examination in children, the debate is ongoing [2]. More and better research is needed concerning cost/risk and benefit of use of CT to ensure that the balance is tilted towards a clear benefit for the patients. The ethics committee did consider radiation risk in the younger patients (six years and older) but had no reservations about the project. Anders Norlund, Lars-Åke Marké, Jean-Luc af Geijerstam 1. Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol. 2001 Feb;176(2):289-96. 2. Griffiths PD, Morrison GD. Computed tomography in children. BMJ. 2004 Oct 23;329(7472):930-2. Competing interests: None declared |
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Steve Goodacre, Clinical Senior Lecturer in Emergency Medicine University of Sheffield, Sheffield, S1 4DA
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The OCTOPUS Study Investigators (1) have shown that CT scanning is more cost-effective than hospital admission for patients attending the emergency department with minor head injury, but is hospital admission an appropriate comparator? It is difficult to identify any benefits accrued to patients by admission to hospital in this study. All three cases requiring neurosurgical intervention were diagnosed after discharge. Meanwhile, a stressful hospital environment, enforced bed rest and exposure to hospital-acquired infections could have worsened outcomes. Before we conclude that CT scanning for minor head injury is a cost- effective use of resources we need to see the results of either a trial or modelling comparing CT scanning to an alternative of discharge without CT. Given the low rate of neurosurgical intervention it is difficult to see how widespread use of CT scanning would provide value for money compared to alternative uses for health care resources. In this respect it seems indefensible that the National Institute for Health and Clinical Excellence have issued guidelines for the use of CT scanning after head injury (2) without any formal cost-effectiveness analysis, whilst rejecting effective treatments for bowel cancer on the basis of cost- effectiveness. 1. Norlund A, Marké L-A, af Geijerstam J-L, Oredsson S, Britton M, OCTOPUS Study. Immediate computed tomography or admission for observation after mild head injury: cost comparison in randomised controlled trial. BMJ 2006;333:469. 2. National Institute for Clinical Excellence. Head injury. Triage, assessment, investigation and early management of head injury in infants, children and adults. London: NICE, 2003. Competing interests: None declared |
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Jane L Ferguson, SpR Penninsula Deanery Royal Devon and Exeter Hospital EX2 5DW, Douglas J Ferguson
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Dear Sir/Madam We read with interest the cited article. The paper highlighted the importance of Health Economics in the provision of medical services. However, the authors failed to mention the potential dangers of irradiation from CT that with the current year on year increases in medical imaging (1) are relevant to the discussion. Irradiation dose from CT is known to be relatively high (2) and thus the potential for further expansion of the role of CT imaging must be balanced not just against cost but also against the potential for any procedure to do harm to the patient. This is especially pertinent in terms of the ethics of this paper in which children (number not identified) aged 7yrs were included in the study and all patients, we are told, gave informed consent. Quite how this was possible in patients with, by definition, head injury could be disputed. CT head exposes a child to a dose of 0.5Gy (appox 100 chest Xrays) (3) and there is some evidence to show a detrimental effect on children’s cognitive development (4). In the US, 33% of all paediatric CT’s are performed in the first 10 yrs when irradiation can do the most harm (5). Dose reduction is achievable (6) but there is no level that is entirely without risk and recently criteria have recently been suggested to reduce the need for CT head in minor head injury patients (7) The guidelines for the management of Head injuries in the UK is well summarised by NICE (8) and differentiates the guidance for children from that for adults which this paper neglects to mention. This paper provides an interesting opportunity to consider costs of CT against observation but care must always be taken to carefully balance potential benefits of any procedures against the dangers. Perhaps the review of the NICE guidelines in June 2007 will clarify these issues better. References: 1. M M Rehani CT: Caution on Radiation Dose Ind J Radiol Imag 2000; 10 (1):19 – 20 2. Shrimpton PC et al Survey of CT practice in the UK Part 2: Dosimetric aspects NRPB-R248. Chilton: NRPB, HMSO1991 3. Herbert M Issues in minor head injury: to CT or not to CT that is the question Emerg Radiol 2000; 7: 7-13 4. Hall P et al Effect of low doses of ionising radiation in infancy on cognitive function in adulthood:Swedish population based cohort studyBr Med J 2004; 328: 19-21 5. Frush DP et al Computed tomography and radiation risks: what pediatric health care providers should know Pediatrics 2003; 112: 951-7 6. Smith et al Variation of Patient Dose in Head CT Br Journal Radiol 1998; 71: 1296-1301 7. Smits M JAMA 2005; 294 (12) : 1519-25 8. National Institute for Clinical Excellence. Clinical Guideline 4. June 2003 Competing interests: None declared |
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