Dissections OBSERVATIONAL

16 May 2009
Evidence-based Medicine for Surgeons

Prevalence of incidental findings in trauma patients detected by computed tomography

imaging
Authors: Barrett TW, Schierling M, Zhou C, et al
Journal: American Journal of Emergency Medicine 2009; 27: 428–435
Centre: Vanderbilt University Medical Center, Nashville, TN, USA
There is an increasing trend in the use of spiral CT scanning in the management of trauma
patients. Although the primary intention of the CT is to identify injuries, unanticipated information
BACKGROUND is often discovered in the course of this testing. Incidental findings, sometimes of a serious
nature and unrelated to the trauma, impose additional demands on the decision-making process.
Authors' claim(s): “...A significant number of trauma patients evaluated with
RESEARCH QUESTION spiral CT are diagnosed with potentially serious incidental findings. For long-
term care and medicolegal concerns, physicians need to inform patients of
Population
these incidental findings and the need for further evaluation.”
Major, adult trauma patients seen
at a Level I, urban trauma centre
in the United States over a 12
IN SUMMARY
month period (Nov 2005 - Oct Incidental findings on spiral CT for trauma
2006).
Type 1 findings Type 2 findings
Indicator variable Number 990 (32%) 1274 (41.2%)
"Complete" spiral CT scan (SCT). Total number of findings reported 2662 1885
Outcome variable At least one incidental finding 1635 (53%)
(either type)
The pattern of unexpected
findings, not related to trauma, Suggesting neoplasms 631 -
seen on SCT that potentially could
pose danger to the patient's Included 196 pulmonary nodules, 99 liver masses, 36 renal masses, 23 brain
present or future health. masses, and 11 breast masses

Comparison type 1 findings - potentially serious results that necessitate further

evaluation and close follow-up
None.
type 2 findings - requiring informing the patient but do not mandate urgent
follow-up.

THE TISSUE REPORT

The commendable element of this study is the efforts that the authors have taken to minimize measurement (observer) bias
in chart review: the pivotal aspect of the data extraction process in this observational study. They also freely admit to the
limitations of the study. They have no idea what happened to the patients on follow up, nor do they have any data of the
number of patients who knew about the existence of these conditions that were detected on the CT. Admittedly, the figure
that they highlight is very large and evokes serious concerns about recommendations for the widespread use of spiral CT in
seriously injured patients. Having ordered a test, it is the responsibility of the physician to inform the patient about findings
and to act on them. Trauma is one specific situation when patients can "fall between the cracks" with respect to continuity of
care and fail to undergo further investigation of the lesions detected.

EBM-O-METER
Evidence level Overall rating Bias levels
Double blind RCT Sampling
Randomized controlled trial (RCT) Comparison
Trash Swiss Safe News-
Prospective cohort study - not randomized cheese worthy Measurement
Life's too Holds water
short for this Full of holes “Just do it”
Case controlled study
Interestingl | Novel l | Feasible l
Case series - retrospective  Ethical l | Resource saving l

The devil is in the details (more on the paper) ... 

© Dr Arjun Rajagopalan
 SAMPLING
Sample type Inclusion criteria Exclusion criteria Final score card
Simple random All "major" trauma Age < 15 years 
patients who
Stratified random Target ?
received a spiral CT
Cluster scan  Accessible ?
Consecutive Intended 3246
Convenience Drop outs 154
Judgmental Study 3092

 = Reasonable | ? = Arguable |  = Questionable

Duration of the study: 1 November 2005 to 31 October 2006

Sampling bias: The criteria for "major" trauma is left undefined. The sample population represents the experience
of a single, referral, Level I trauma centre in the USA.

COMPARISON
Randomized Case-control Non-random Historical None

Controls - details
Allocation details The study was carried out as a retrospective chart review using a detailed, objective
methodology. A complete s[iral CT was defined as imaging of the head, cervical spine, chest,
abdomen, and pelvis, thoracic, and lumbar spine. An "incidental" finding was defined as an
unexpected finding seen on CT, not related to trauma, that potentially could pose danger to
the patient's present or future health. All findings were classifed as: type 1 findings -
potentially serious results that necessitate further evaluation and close follow-up, and type 2
findings - requiring informing the patient but do not mandate urgent follow-up.
Comparability -
Disparity -

Comparison bias: Although the authors differentiate the characteristic of those with and without significant CT
findings, this was not the primary intention of the study. Attempting to delineate associations between the CT
findings and baseline data differences is not valid.

MEASUREMENT
Measurement error
Device used Device error Observer error
Gold std.

Device suited to task

Training

Scoring

Blinding
Repetition

Protocols

Y ? N

1.Standardized chart review methodolgy Y N ? Y Y - Y

A 2-month, pilot period preceded the actual study. Four chart reviewers (2 faculty physicians and 2 resident physicians)
conducted a 2-month pilot study reviewing the charts of trauma patients and a uniform method of data recording was
established. A uniform data abstraction form was designed that clearly listed examples of types 1 and 2 incidental
findings in addition to examples of findings not considered of clinical significance. Two independent case manager
reviewers recorded the age, sex, mechanism of trauma, and final patient disposition. The physician reviewers were
blinded to these patient characteristics to limit potential bias.
Measurement bias: Only thirteen percent of the charts were reviewed by two observers. The inter-observer
variability was estimated at a Kappa value of 0.67. The chart review relied upon the attending radiologist's
interpretation of the CT scan. The level of detail in the report varied considerably between the various radiologists.

© Dr Arjun Rajagopalan