Projected cost savings and feasibility of clinical decision rules for mild traumatic brain injury in Nigerian tertiary hospital: A comparative analysis of the Canadian CT head rule and New Orleans criteria
Selekeowei Peter Kespi KpuduweiObjectives:
The high cost and limited availability of computed tomography (CT) scanning in resource-limited settings necessitate tools to guide its rational use. The feasibility and impact of established clinical decision rules (CDRs) in such environments require evaluation. To assess the potential financial impact of implementing the Canadian CT head rule (CCHR) or New Orleans Criteria (NOC) on CT scan rates and to discuss the practical challenges of adoption in a Nigerian hospital.
Materials and Methods:
Using prospective data of traumatic brain injury (TBI) patients with Glasglow Coma Scale (GCS) 13 to 15 in 2023, we calculated the proportion for whom each CDR would recommend a CT scan. The negative predictive values (NPV) were analyzed to assess safety. Contextual challenges related to cost, manpower, and training were evaluated.
Results:
A total of 103 patients with mild traumatic brain injury (mTBI) were included. NOC would have recommended CT for 83/103 patients (80.6%), while the CCHR would have recommended it for 77/103 patients (74.8%). Clinically significant brain injury occurred in 45/103 patients (43.7%), and 21/103 patients (20.4%) required neurosurgical intervention. For prediction of neurosurgical intervention, NOC demonstrated a sensitivity of 95.0%, specificity of 20.0%, positive predictive value (PPV) of 22.9%, and NPV of 94.1% (95% confidence intervals [CI] 71.3–99.9%). CCHR demonstrated a sensitivity of 90.0%, specificity of 26.3%, PPV of 23.4%, and NPV of 91.3% (95% CI 72.0–98.9%). The CCHR could potentially reduce CT utilization by 25.2% compared with a scan-all strategy, resulting in substantial cost savings.
Conclusion:
Implementing either CDR is feasible and would introduce a standardized, evidence-based approach to mTBI management. The CCHR may be marginally more efficient in reducing unnecessary imaging. Successful implementation will require targeted training of emergency department staff, integration into local clinical protocols, and consideration of the significant patient-borne financial burden.