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The LIMIT clinical decision instrument reduces neuroimaging compared to unstructured clinician judgement in recurrent
Derek Isenberg1, Melissa Gunchenko1, Rachel Fenstermacher1
1Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, 1314 West Ontario Street, Jones Hall, 10(th) Floor, Philadelphia, PA 19130, United States of America.
Insights
The LIMIT clinical decision instrument (CDI) can reduce brain CT scans for recurrent seizures. This tool is more effective than physician judgment in determining the need for emergent neuroimaging.
Area of Science:
- Neurology
- Emergency Medicine
- Radiology
Background:
- Emergency physicians frequently use brain CT scans to diagnose intracranial pathology in patients presenting with seizures.
- The LIMIT (Let's Image Malignancy, Intracranial Hemorrhage, and Trauma) clinical decision instrument (CDI) was previously validated to identify patients with recurrent seizures who require emergent neuroimaging, demonstrating a high negative predictive value (NPV) of 99.9%.
- This study aimed to compare the efficacy of the LIMIT CDI against unstructured physician judgment in evaluating the need for emergent neuroimaging in patients with recurrent seizures.
Observation:
- An observational study included 1108 patients presenting with seizures, with 24 excluded due to lack of follow-up.
- Brain CT scans were used as a proxy for physician judgment.
- The LIMIT CDI identified 90% of patients with positive CT scans, while clinician judgment identified 100%.
Findings:
- The LIMIT CDI demonstrated a sensitivity of 90%, specificity of 81.1%, and an NPV of 99.9%.
- Unstructured physician judgment achieved 100% sensitivity, 67.8% specificity, and 100% NPV.
- Implementing the LIMIT CDI could reduce brain CT utilization by 13.3% compared to unstructured clinical judgment.
Implications:
- The LIMIT CDI shows potential to decrease unnecessary brain CT scans in the emergency department for patients with recurrent seizures.
- While requiring further validation in larger cohorts, the LIMIT CDI appears to be a more effective tool than unstructured physician judgment for guiding neuroimaging decisions.
- Optimizing the use of neuroimaging through validated clinical decision instruments can improve efficiency and resource allocation in emergency care settings.
Introduction:
Given the many causes of seizures, emergency physicians often utilize brain computed tomography (CT) to evaluate for intracranial pathology. Previously, we have validated the LIMIT (Let's Image Malignancy, Intracranial Hemorrhage, and Trauma) clinical decision instrument (CDI) study to determine which patients with recurrent seizures require emergent neuroimaging. The LIMIT CDI had a negative predictive value (NPV) of 99.9%. Here, we seek to compare the LIMIT CDI to unstructured physician judgement.
Methods:
This was an observational study of patients who presented with a complaint of seizure. A research assistant reviewed the electronic medical record (EMR) for each patient and applied the LIMIT CDI. Brain CT was used as a proxy for physician judgement. If no brain CT was ordered and the patient was discharged from the emergency department (ED), the EMR was searched to determine whether patient had any medical visits within one year of the index visit. If the patient had no new neurological findings on follow up or abnormalities on follow up neuroimaging, this was considered a patient who did not require a brain CT in the ED. Patients who did not have a CT on their ED visit and had no follow up visits were excluded.
Results:
1739 patients were screened and 1108 patients were in the final analysis. 24 patients who did not have a brain CT and no follow up visits were excluded. 10 patients (0.9%) had positive CTs. 9/10 of the patients were identified by the CDI resulting in a sensitivity of 90%, specificity of 81.1% and a negative predictive value (NPV) of 99.9%, and a negative likelihood ratio (LR) of 0.12. Clinician judgement identified all 10 patients with a positive brain CT for a sensitivity of 100%, specificity of 67.8%, and a NPV and negative LR of 100% and 0, respectively. Using unstructured clinical judgement, EPs ordered 364 brain CTs while only 217 brain CTs would have been ordered using the CDI, a reduction of 13.3%.
Discussion:
When compared to unstructured physician judgement, the LIMIT CDI would have reduced brain CT usage by more than 13%. Although the LIMIT CDI needs to be validated in a larger set of patients, it performed better than unstructured physician judgement for evaluating need for emergent neuroimaging after recurrent seizures.
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