Who Orders a Head CT?: Perceptions of the Cirrhotic Bleeding Risk in an International, Multispecialty Survey Study. Issue 7 (August 2017)

• Record Type: Journal Article
• Authors: Mazer, Laura M.; Méan, Marie; Tapper, Elliot B.
• Is Part Of: Journal of clinical gastroenterology. Volume 51:Issue 7(2017)
• Publication Date: 2017-08
• Subjects: liver disease -- encephalopathy -- computed tomography -- cirrhosis -- evidence based medicine; Gastroenterology -- Periodicals; Digestive organs -- Diseases -- Periodicals; Gastroenterology -- Periodicals; Digestive organs -- Diseases; Gastroenterology; Periodicals; Periodicals; 616.33005
• DOI: 10.1097/MCG.0000000000000775
• Languages: English
• ISSNs: 0192-0790

Abstract

Abstract : Objective: Traditional coagulopathic indices, including elevated international normalized ratio, do not correlate with bleeding risk in patients with cirrhosis. For this reason, head computed tomography (CT) has a low yield in cirrhotic patients with altered mental status and no trauma history. The initial diagnostic evaluation, however, is often made by nongastroenterologists influenced by the so-called "coagulopathy of cirrhosis." We sought to examine the prevalence, impact, and malleability of this perception in an international, multispecialty cohort. Design: An electronic survey was distributed to internal medicine, surgery, emergency medicine, and gastroenterology physicians. Respondents were presented with a cirrhotic patient with hepatic encephalopathy, no history of trauma, and a nonfocal neurological examination. Respondents rated likelihood to order head CT at presentation, after obtaining labs [international normalized ratio (INR) 2.4 and platelets 59×10 3 /μL], and finally after reading the results of a study demonstrating the low yield of head CT in this setting. Results: In total, 1286 physicians from 6 countries, 84% from the United States. Of these, 62% were from internal medicine, 25% from emergency medicine, 8% from gastroenterology, and 5% from surgery. Totally, 47% of respondents were attending physicians. At each timepoint, emergency physicians were more likely, and gastroenterologists less likely, to scan than all other specialties ( P <0.0001). Evidence on the low yield of head CT reduced likelihood to scan for all specialties. Qualitative analysis of open-ended comments confirmed that concern for "coagulopathy of cirrhosis" motivated CT orders. Conclusions: Perceptions regarding the coagulopathy of cirrhosis, which vary across specialties, impact clinical decision-making. Exposure to clinical evidence has the potential to change practice patterns. Abstract : Supplemental Digital Content is available in the text.