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Year : 2021  |  Volume : 11  |  Issue : 3  |  Page : 234-241

Cost-Effectiveness Analysis of Head Computed Tomography in Children with Mild Traumatic Brain Injury: A Retrospective Study

Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand

Date of Submission03-Mar-2021
Date of Decision15-Mar-2021
Date of Acceptance19-Mar-2021
Date of Web Publication12-Jun-2021

Correspondence Address:
Thara Tunthanathip
Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijnpnd.ijnpnd_8_21

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Background: Head computed tomography (CT) is used as a diagnostic tool for intracranial injury following traumatic brain injury (TBI). However, the long-term effects of radiation exposure should be of concern in children. This study compared the cost-effectiveness of the early head CT (ECT) strategy with that of initial conservative treatment with parent education of the nonearly CT (NECT) in pediatric TBI with a Glasgow Coma Scale (GCS) score of 15. Methods: A retrospective study was conducted with TBI children with a GCS of 15, who were treated at an emergency department (ED). The costs and outcomes of the children were recorded. The authors used a decision tree model (Plant-A-Tree, International Decision Support Initiative, United Kingdom) to compare the cost-effectiveness analysis of two strategies. The incremental cost-effectiveness ratio (ICER) was also calculated. Results: For the ECT group, the rate of the positive results following head CT was 17.6%, and the common intracranial injuries were epidural hematoma, skull fracture, and subdural hematoma in 11.5%, 9.8%, and 6.6%, respectively. The children in the ECT group who underwent surgery were 3.2%. For the NECT group, revisions were observed in 5.3%, and all patients with revision underwent CT. Therefore, the frontal contusion was observed in 10% following CT, and none underwent surgery in the NECT group. From a healthcare provider’s perspective, the expected cost of the ECT group was US $597.49, whereas the expected cost of the NECT group that included overall costs at ED was US $115.27. The expected outcome of the ECT group was less than the NECT group that caused the base-case ICER to be negative (−US $30,715.28 per outcome gained). A sensitivity analysis revealed that an early CT strategy became a dominant strategy that needed a low revision rate but a high rate of positive findings after head CT. Conclusion: The initial conservative treatment was the dominant strategy. This strategy was safe and effective and could diminish the unnecessary exposure to radiation in children.

Keywords: Cost-effectiveness analysis, economic evaluation, mild traumatic brain injury, pediatric traumatic brain injury

How to cite this article:
Tunthanathip T, Phuenpathom N, Sae-heng S, Oearsakul T, Sakarunchai I, Krewborisutsakul A, Taweesomboonyat C. Cost-Effectiveness Analysis of Head Computed Tomography in Children with Mild Traumatic Brain Injury: A Retrospective Study. Int J Nutr Pharmacol Neurol Dis 2021;11:234-41

How to cite this URL:
Tunthanathip T, Phuenpathom N, Sae-heng S, Oearsakul T, Sakarunchai I, Krewborisutsakul A, Taweesomboonyat C. Cost-Effectiveness Analysis of Head Computed Tomography in Children with Mild Traumatic Brain Injury: A Retrospective Study. Int J Nutr Pharmacol Neurol Dis [serial online] 2021 [cited 2022 Aug 19];11:234-41. Available from:

   Introduction Top

Children with traumatic brain injury (TBI) are one of the public health problems that the Centers for Disease Control and Prevention have considered a major problem.[1] Physical disabilities and mortality in children are obstacles for the country to address next. TBI is defined as the alteration in the brain’s function, or other evidence of brain pathology from an external force loading to the head and is divided into mild, moderate, and severe subgroups according to the Glasgow Coma Scale (GCS).[2],[3],[4] In addition, mortality in children following TBI has been reported in the range of 3.2% to 13.18%, whereas serious disabilities have been found in 0.3% to 0.8% of those cases.[5],[6],[7]

Nowadays, computed tomography (CT) of the brain is widely used as a diagnostic tool for intracranial injury following TBI. Hence, the rate of head CT in patients following TBI increased from 13.1% in 1996 to 40.7% in 2007, based on the study of Larson et al.[8] Although head CT is convenient for managing pediatric TBI, Sheppard et al.[9] conducted a systematic review for the long-term effect from radiation exposure in children aged 0 to 18 years who were exposed to head CTs between 1996 and 2012, and found that a CT of the brain was significantly associated with brain tumors (odds ratio [OR] 1.29; 95% confidence interval [CI] 0.66–1.93). In addition, Pearce et al. studied children who were first exposed to CT between 1985 and 2002, from the national health database and found that 74 patients out of 178,604 children who underwent CT developed leukemia (OR 3.18; 95% CI 1.46–6.94) and 135 patients out of 176,587 patients developed a brain tumor (OR 2.82; 95% CI 1.33–6.03) during the follow-up until 2008.[10] From the literature, the long-term effect of ionizing radiation should be avoided if there is no indication for CT.[10]

There has been debate about children with mild TBI with a GCS score of 15 and the need for a CT of the brain. Therefore, the Pediatric Emergency Care Applied Research Network (PECARN),[11] Canadian Assessment of Tomography for Childhood Head Injury,[12] and Children’s Head Injury Algorithm for the Prediction of Important Clinical Events[13] are clinical decision rules to regulate the need for a CT of the brain in pediatric patients with a minor TBI. Moreover, over-investigation results in high-cost treatments and an economic burden in resource-limited settings. Smits et al. performed a study in 2010 to evaluate the costeffectiveness of CT in the Netherlands in minor TBI patients.[14] The results showed that selecting a CT based on clinical criteria strategies provided a less costly and more effective strategy than CT in all minor TBI.[14] Conversely, Dalzei et al. from Australia and New Zealand conducted an economic evaluation study in 2019, and demonstrated that the usual care cost strategy was US $6,390, whereas the cost of selecting a CT based on clinical criteria strategy was US $6,423 to $6,457.[15] Therefore, the usual care strategy dominated rather than other strategies in prior studies.[15]

In real-world situations, patients met the criteria for a CT of the brain, but their parents were concerned about radiation-induced cancers and denied the investigation, especially TBI children with a GCS of 15. Therefore, there is a controversy about the need for a CT in pediatric TBI with a score of 15, and a lack of evidence involved in the economic evaluation of a head CT in this specific group. In the face of this gap, this study aimed to compare the cost-effectiveness of an early head CT (ECT) strategy with that of initial conservative treatment with a giving information strategy or nonearly CT (NECT) group with a GCS score of 15.

   Methods Top

Study population

The study design of the present study was a retrospective cohort study and children aged younger than 15 years, who suffered from isolated TBI with a GCS score of 15, and those who were treated at the emergency department (ED) of a trauma center of Southern Thailand between January and December 2019, were included. Additionally, all children with TBI were determined the criteria for a head CT according to the PECARN criteria[11],[16] in the authors’ institute and were admitted to the pediatric neurosurgical ward or pediatric intensive care unit (ICU). Patients who had unavailable complete medical records during admission or denied further treatment were excluded because these patients were a loss to follow-up, and the one-month follow-up outcomes could not be estimated.

All of the ECT group were admitted to the authors’ institute. In detail, children with positive intracranial injury were admitted to the pediatric ICU, while children with a negative finding were admitted to the pediatric neurosurgical ward. For the NECT group, children without a revisit received advice about early warning signs so as to return to the hospital for reevaluation and were discharged from the ED and scheduled a follow-up at a neurosurgical clinic. All children with a revision in the NECT group underwent a head CT and were admitted to the pediatric neurosurgical ward or pediatric ICU depending on the result of the head CT, which was the same protocol as the ECT group.

The study was performed with the approval of the Human Research Ethics Committee of Faculty of Medicine, Prince of Songkla University (REC.63-438-10-1). Because the present study was a retrospective cohort study design, the Ethics Committee approved to waive the informed consent. However, the patients’ identification numbers were encoded before analysis. Moreover, the present study was performed and reported the results adhering to the Consolidated Health Economic Evaluation Reporting Standards statement.[17]

Decision tree model

The authors reviewed the clinical characteristics, results of the head CT, treatment, costs, and 1-month follow-up outcomes from the computer-based medical records of the hospital for building a decision-analytic model. Following [Figure 1], all TBI children with a GCS score of 15 were assessed for the need of a head CT based on the PECARN criteria[16] that could be divided into the ECT group and the NECT group.
Figure 1 The decision tree model of pediatric traumatic brain injury with a Glasgow Coma Scale score of 15

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All children who were assessed for a CT of the brain were admitted. For the patients who had a positive finding after CT, treatment options comprised either conservative treatment or surgical treatment. Conservative treatment included neurological observation, pain control, wound care, and other medication. Sometimes, patients underwent a follow-up CT of the brain depending on the neurosurgeon’s opinion. Surgical treatment included craniotomy/craniectomy with clot removal and neurointervention, such as, an intracranial monitoring procedure. For the postoperative care, patients received general care in the pediatric ICU, a follow-up CT of the brain, and medication. Children with a negative result after a CT received conservative treatment, such as, outpatient department (OPD) or inpatient department.

In the NECT group, children did not initially receive a head CT, and their parents were advised about the emergency symptoms. Therefore, patients who showed no deterioration went to the hospital for a scheduled follow-up. On the other hand, children with deterioration, such as, alteration of consciousness, weakness, or seizure, revisited. All revisited children received a CT of the brain, and the same treatment protocol as the ECT group after a head CT.

Economic evaluation

In the cost-effectiveness analysis (CEA), the outcome was measured as a multiplication between the number of patients and each King’s Outcome Scale for Childhood Head Injury (KOSCHI) score category[17]; therefore, the GCS scores were implied in the range of 0 to 1 as follows: death (0), vegetative state (0.25), severe disability (0.5), moderate disability (0.75), and good recovery (1). Consequently, effectiveness was measured as the gained outcome.

The cost of the treatment was reviewed from the hospital database from the perspective of the healthcare provider. Hence, the direct medical costs and outcome of the ECT group were compared with the NECT group at a 1-month follow-up OPD visit. The means costs within the specified items were performed in the base-case analysis. In addition, direct nonmedical costs and indirect costs were not included. All costs were in US dollars and set to the 2019 price level (December 25, 2019).

For this comparison, a deterministic CEA was performed using the decision tree model (Plant-A-Tree, International Decision Support Initiative, United Kingdom) [Figure 1]. The incremental cost-effectiveness ratio (ICER) was estimated by dividing the difference in costs by the difference in outcomes for the base-case analysis [Equation 1].[18],[19] Moreover, if the time horizon of the CEA was less than 1 year, both the costs and outcomes were not discounted.

Sensitivity analysis

The uncertainties of the decision-analytic model’s parameters, which affected the ICER, were evaluated as a one-way sensitivity analysis (OWSA) and a two-way sensitivity analysis (TWSA). The OWSA demonstrated a change in the ICER [Equation 2][17],[20] when the model allowed the input parameters to be changed according to the 95% CI for each parameter. The results of the OWSA were demonstrated in the tornado diagram. Additionally, the OWSA was performed according to the probability of chance node, and the results of the ICER difference were presented as a scatter plot.

For the TWSA, the model allowed the probabilities of two chance nodes being changed synchronously, and the output of the changed ICER was presented as a surface plot.[21],[22]

Statistical analysis

All clinical characteristics of the present cohort were analyzed using the R version 3.6.1 software (R Foundation, Vienna, Austria), and the economic evaluation was analyzed with the Microsoft Excel 2010 program (Microsoft Corporation, USA).

   Results Top

Clinical characteristics of the study population

Of the 187 children with a GCS score of 15, more than two-thirds were male, and the mean age of the patients was 62.44 months with a range from 2 to 175 months (standard deviation [SD] 53.81). Moreover, almost all of the patients had no comorbidities, and none took the antiplatelet or anticoagulant before TBI. Falling to the ground level, motorcycle accident, and object striking the head were the common mechanisms of injury at 54.5%, 19.3%, and 12.3%, respectively, of the cases in the present cohort. More than half had a scalp hematoma seizure, while early post-traumatic seizure was observed in 1.6% of the cases. Sixty-eight patients (36.4%) indicated a head CT and underwent investigation. The remaining 119 patients did not initially have a CT scan; 95 children did not meet the criteria and 24 patients were denied a CT scan by their parents. A summary of the clinical characteristics is shown in [Table 1]. Moreover, 6.9% of the cases were admitted to the pediatric ICU, while 58.3% were discharged from the ED. In addition, the median length of hospital stay was 2 days (interquartile range 5).
Table 1 Baseline clinical characteristics (N = 187)

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For the ECT group, the rate of the positive results following a head CT was 17.6%, and the common intracranial injuries were epidural hematoma, skull fracture, and subdural hematoma in 11.5%, 9.8%, and 6.6%, respectively. Hence, 3.2% of the children who had an intracranial hematoma underwent surgery; a craniotomy with clot removal was performed in all cases. Intracranial monitoring or other kinds of neurological interventions were not performed in the present cohort. For the NECT group, the rate of revision was observed in 5.3% of the cases, and intracranial injuries following a head CT were observed in 10%. In detail, one patient, who was an 8-year-old boy, suffered from a car accident without ejection. His physical examinations were within normal limits, and his GCS scores were 15, which did not meet the head CT criteria. He revisited 22 hours later because he vomited; therefore, he underwent to head CT. Imaging showed a small focal contusion at the left high frontal lobe about 0.6 cm in size, and he was admitted and treated by conservative treatment.


Almost the entire present cohort had a follow-up KOSCHI’s outcome with a good recovery. Nine children (4.8%), who had intracranial injuries, had a moderate disability; eight patients were in the ECT group, and three patients underwent craniotomy with clot removal [Table 2].
Table 2 Outcome according to each terminal node

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For building the decision-analytic model, the clinical characteristics and KOSCHI’s outcome were used. The CT of the brain was the standard diagnostic test for intracranial injury in the decision-analytic model; therefore, they used the prevalence of positive findings following a head CT as the probabilities. Moreover, the costs and outcomes were collected from the hospital database [Table 3], and probabilities of the ECT and NECT groups were implied in the decision tree model. The expected costs and expected outcomes of each group were calculated with the folding back analysis [Figure 2].[23],[24],[25],[26],[27]
Table 3 Parameters of the decision tree model

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Figure 2 The decision tree model with folding back analysis

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[Table 4] shows the results of the base-case analysis. The expected cost of the ECT group was US $597.49, whereas the expected cost of the NECT group was US $115.27. Because the expected outcomes of the ECT group were less than the NECT group, the base-case ICER was negative at US $−30,715.28 per outcome gained.
Table 4 Base-case results for early computed tomography compared with nonearly computed tomography

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Therefore, the uncertainty of the economic model was estimated with the OWSA and TWSA. [Figure 3]A shows the tornado diagram, while [Figure 3]B reveals the scatter plot of the ICER difference based on the probabilities of the CT results, surgical treatment, and revision. A positive relationship was observed in the changed ICER in the probability of positive findings on the head CT (pCT) and the probability of surgery/neurointervention (pSx), while a negative correlation was found between the ICER difference and probability of revision (pRevision).
Figure 3 Graphs for one-way sensitivity analysis: (A) tornado diagram and (B) the scatter plots

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In addition, the results of the TWSA are shown in [Figure 4]A and BA and B. The ICER changed and rose with the pSx and pCT. Thus, the results inferred that the ECT group would become cost-effective with a high prevalence of both the pCT and pSx. On the other hand, the ICER changed to be more negative with a high pRevision and low probabilities of pCT, while the ICER changed to positive at a low revision rate and high rate of positive findings after a head CT.
Figure 4 Three-dimensional surface plots for two-way sensitivity analysis. (A) Probabilities of surgical treatment and a positive result following head CT. (B) Probabilities of revision and a positive result following head CT

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   Discussion Top

CT in children with TBI has advantages and disadvantages. Ionic radiation exposure has been a concern in children. Therefore, a CT of the brain is controversial in children with a GCS score of 15. The results showing a positive rate of CT in this group was infrequent in 17.6% of cases, and the need for surgical management was rare in 3.2%. Moreover, male predominance was observed in the present cohort because they had activities that were a risk of an accident higher than females.[3],[4],[5],[6],[7] Similarly, Tunthanathip et al. studied 948 TBI children and found that GCS scores of three to 12 were predictors of intracranial injuries.[6] Moreover, children with a GCS scores of 13 to 15 needed an operation (3.2%), while surgical treatment in moderate–severe TBI ranged between 15.7% and 22.7%.[6] Moreover, the revision rate in the present study found that in 3.2% of cases, the concordance results were similar to what had been shown in previous studies. Wang et al.[28] found a revision rate in minor TBI of about 2%, and the factors associated with the revision were old age and more comorbidities.

Initial conservative treatment with giving information for pediatric TBI with a GCS of 15 was performed and was the dominant strategy from an economic perspective. In the present study, more outcome loss was observed in the ECT group that caused the negative value of the ICER. However, an early CT strategy became the dominant strategy that needed a low revision rate, but a high rate of positive findings after a head CT as found by the TWSA.

A lack of evidence was mentioned in the cost-effectiveness of CT in minor TBI in children. Nishijima et al. studied a comparison between the clinical prediction rules strategy and a CT of the brain in children with minor head trauma and found that the clinical decision rule was the cost-effective approach for children with minor TBI from less quality adjusted life year loss and less costly.[29] On the other hand, Dalzei et al. reported that using clinical decision rule strategies were not found to be the dominant strategy for usual care in Australia and New Zealand.[15] This was explained from the difference of the settings and various parameters of the decision-analytic model. However, a head CT was a necessary investigation for the early diagnosis of intracranial injuries in the high-risk group. Campbell et al. estimated that from a medical payer’s perspective, it should be proposed that a head CT is a cost-effective strategy when a suspected abuse mechanism is considered for an infant.[30] This is because early diagnosis of inflicted TBI in an infant was less costly and had an improved outcome. Hence, the head CT was effective in the high-risk group for intracranial injuries.[30]

From the authors’ knowledge, the present study was the first paper demonstrating the cost-effectiveness of a head CT in this controversial population. The neurological status observation and advice to their parents could be performed for balancing over-investigation and radiation exposure in children; none underwent surgery when children revisited, and all had a favorable outcome. Moreover, the present study revealed that not all children who met the clinical decision rules underwent a head CT in real-world situations. The long-term effects following a CT were a serious topic with parental concern in approximately 20.2% (24/119); therefore, their patients denied to initially undergoing the head CT. However, the limitations of the present study should be acknowledged in which diagnosis of intracranial injuries was based on only the head CT. Magnetic resonance imaging (MRI) of the brain has higher sensitivity than head CT to detect intracranial injuries[31]; however, MRI is very time-consuming and needs more cooperation from children. Subsequently, this imaging has not been a routine investigation for TBI diagnosis in our institute. Moreover, the outcomes of this study were KOSCHI’s score, and the analysis was the CEA. Future studies using quality-adjusted life years as an outcome would be warranted to conduct cost–utility analysis (CUA). Consequently, policymakers usually use the results of CUA for decision-making and treatment strategies.

   Conclusion Top

Because the initial non-CT strategy had less outcome loss and was less costly, this dominated more than the early CT strategy. Balancing the unnecessary head CT scan in TBI children with a GCS of 15 could be implied in a resource-limited setting.

Research quality and ethics statement

The authors of this manuscript declare that this scientific work complies with the reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network (Consolidated Health Economic Evaluation Reporting Standards − CHEERS Checklist). The authors also attest that this clinical investigation was determined to require the Institutional Review Board/Ethics Committee review, and the corresponding protocol/approval number is (REC.63-438-10-1).

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2], [Table 3], [Table 4]


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