Who Orders a Head CT?: Perceptions of the Cirrhotic Bleeding Risk in an International, Multispecialty Survey Study

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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 59×103/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.

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