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