Published online August 1, 2007
PEDIATRICS Vol. 120 No. 2 August 2007, pp. 295-304 (doi:10.1542/peds.2007-0437)
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ARTICLE

Cost-effectiveness of Head Computed Tomography in Infants With Possible Inflicted Traumatic Brain Injury

Kristine A. Campbell, MD, MSca, Rachel P. Berger, MD, MPHb, Lorraine Ettaro, PhD, MPHc and Mark S. Roberts, MD, MPPd

a Division of Safe and Healthy Families, Department of Pediatrics, University of Utah, Salt Lake City, Utah
b Division of Child Advocacy, Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
c University of Pittsburgh Center for Rural Health Practice, Bradford, Pennsylvania
d Section of Decision Sciences and Clinical Systems Modeling, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania

OBJECTIVE. Early diagnosis of inflicted traumatic brain injury may reduce morbidity and mortality associated with repeated inflicted traumatic brain injuries. We undertook this study to estimate the cost-effectiveness of a policy of head computed tomography (CT) for inflicted traumatic brain injury in selected infants seen in an emergency department.

METHODS. We constructed Markov models to compare a policy of CT to no CT in an asymptomatic 5-week-old infant with either (1) unexplained scalp bruising or (2) a history of an apparent life-threatening event. Health states modeled were no inflicted traumatic brain injury, misdiagnosed inflicted traumatic brain injury, mild inflicted traumatic brain injury (diagnosed or undiagnosed), and severe and fatal inflicted traumatic brain injury. Infants with undiagnosed inflicted traumatic brain injury were at increased risk of repeat inflicted traumatic brain injury. We used available literature to estimate probabilities, costs, and outcomes. The models terminated at death or at 52 weeks of age. Outcomes considered were severe and fatal inflicted traumatic brain injury cases averted through early detection of mild inflicted traumatic brain injury.

DATA SOURCES. We conducted a literature review for estimates of inflicted traumatic brain injury incidence, outcome probabilities, and medical and societal costs. Wide ranges were set for sensitivity and Monte Carlo analyses.

RESULTS. From a medical payer perspective, head CT for inflicted traumatic brain injury in infants with unexplained scalp bruising saved money. Sensitivity analysis demonstrated costs less than $50000 per severe or fatal inflicted traumatic brain injury averted in scenarios in which initial inflicted traumatic brain injury prevalence was >3%. From a societal perspective, costs of child protection made head CT for inflicted traumatic brain injury more expensive.

CONCLUSIONS. From a medical payer perspective, our models demonstrate that CT for inflicted traumatic brain injury can be cost-effective and improve outcomes. The finding of higher societal cost reflects the substantial short-term costs of child protection. Our study supports a low medical threshold for CT screening and highlights the need for improved understanding of long-term costs and outcomes of child abuse.

Key Words: abuse • shaken-baby syndrome • cost-effectiveness • computed tomography

Abbreviations: iTBI—inflicted traumatic brain injury • CT—computed tomography • ED—emergency department • ALTE—apparent life-threatening event

Accepted Mar 23, 2007.