For children at intermediate risk for clinically important traumatic brain injuries (ciTBIs), parental use of a decision aid does not affect the frequency of emergency department (ED) computed tomography (CT) but improves decision quality and decreases health care utilization at 7 days, according to a study published in JAMA Network Open.

A team of US-based researchers conducted a cluster randomized trial in 7 US EDs to assess the differences between use of a decision aid by parents of children at intermediate risk for ciTBI and usual care.

The main outcomes measured were parent knowledge of a child’s risk for ciTBI and the diagnostic options available. The secondary outcomes were decisional conflict, decision-making engagement among parents, the ED CT rate, 7-day healthcare utilization, and missed ciTBI.

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Children—ages 2 to 18 years—with minor head trauma who were at intermediate risk for ciTBI (and their parents) were eligible to participate in the study.

Clinicians (attending physicians, pediatric emergency medicine fellows, and advanced practitioners) were randomly assigned to either usual care or shared decision making facilitated by the Head CT Choice decision aid, which educates caregivers about the definitions of concussion, differences between concussion and other forms of TBI, and children’s risk for ciTBI. This aid also helps caregivers to identify signs and symptoms that may require a repeated ED visit.

A total of 971 children (average age, 6.7 years; 59% male) and 172 clinicians were enrolled; 493 children were randomly assigned to the decision aid cohort and 478 were assigned to usual care.

The investigators reported greater knowledge among parents in the decision aid cohort compared with parents in the usual care cohort (average number of questions correctly answered, 6.2 vs 5.3; average difference, 0.9). In addition, parents in the decision aid cohort had less decisional conflict (average decisional conflict score, 14.8 vs 19.2; average difference, –4.4) and were more engaged in CT decision making (average observing patient involvement score, 25.0 vs 13.3; average difference, 11.7).

No significant differences in ED CT rates were observed, but the average number of imaging tests conducted was lower in the decision aid group. No ciTBIs were missed in either group.

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“Use of the Head CT Choice decision aid in parents of children with minor head trauma at intermediate risk of ciTBIs was associated with greater parent knowledge of the risk of ciTBI and the available diagnostic options,” the authors concluded. “It also was associated with less decisional conflict, greater clinician trust, and greater involvement of parents in CT decision-making. The intervention did not reduce the ED CT rate but safely decreased health care utilization at 7 days.”


Hess EP, Homme JL, Kharbanda AB, et al. Effect of the head computed tomography choice decision aid in parents of children with minor head trauma: a cluster randomized trial. JAMA Netw Open. 2018;1(5):e182430.