Article Text

Download PDFPDF

Should all anticoagulated patients with head injury receive a CT scan? Decision-analysis modelling of an observational cohort
  1. Maxine Kuczawski1,
  2. Matt Stevenson1,
  3. Steve Goodacre1,
  4. M Dawn Teare1,
  5. Shammi Ramlakhan2,
  6. Francis Morris2,
  7. Suzanne Mason1
  1. 1School of Health and Related Research, University of Sheffield, Sheffield UK
  2. 2Emergency Department, Northern General Hospital, Sheffield UK
  1. Correspondence to Professor Suzanne Mason; s.mason{at}


Objectives It is not currently clear whether all anticoagulated patients with a head injury should receive CT scanning or only those with evidence of traumatic brain injury (eg, loss of consciousness or amnesia). We aimed to determine the cost-effectiveness of CT for all compared with selective CT use for anticoagulated patients with a head injury.

Design Decision-analysis modelling of data from a multicentre observational study.

Setting 33 emergency departments in England and Scotland.

Participants 3566 adults (aged ≥16 years) who had suffered blunt head injury, were taking warfarin and underwent selective CT scanning.

Main outcome measures Estimated expected benefits in terms of quality-adjusted life years (QALYs) were the entire cohort to receive a CT scan; estimated increased costs of CT and also the potential cost implications associated with patient survival and improved health. These values were used to estimate the cost per QALY of implementing a strategy of CT for all patients compared with observed practice based on guidelines recommending selective CT use.

Results Of the 1420 of 3534 patients (40%) who did not receive a CT scan, 7 (0.5%) suffered a potentially avoidable head injury-related adverse outcome. If CT scanning had been performed in all patients, appropriate treatment could have gained 3.41 additional QALYs but would have incurred £193 149 additional treatment costs and £130 683 additional CT costs. The incremental cost-effectiveness ratio of £94 895/QALY gained for unselective compared with selective CT use is markedly above the threshold of £20–30 000/QALY used by the UK National Institute for Care Excellence to determine cost-effectiveness.

Conclusions CT scanning for all anticoagulated patients with head injury is not cost-effective compared with selective use of CT scanning based on guidelines recommending scanning only for those with evidence of traumatic brain injury.

Trial registration number NCT 02461498.

  • Warfarin

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

View Full Text

Statistics from


  • Contributors All authors provided substantial contributions to the conception, design, acquisition of the data, or analysis and interpretation of the study data. MK drafted the article and all authors contributed to its revision for important intellectual content. All authors approved the final version. SM is the guarantor. All authors agree to be accountable for all aspects of the work ensuring that questions related to accuracy or integrity of any party of the work are appropriately investigated and resolved.

  • Funding This paper presents independent research commissioned by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme grant reference number PB-PG-0808-17148. This work is sponsored by Sheffield Teaching Hospitals NHS Foundation Trust, reference number STH15705.

  • Disclaimer The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

  • Competing interests None declared.

  • Ethics approval NRES Committee Yorkshire and The Humber—Sheffield: 11/H1308/13.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.