Overuse of computed tomography for mild head injury: A systematic review and meta-analysis

Maryam Saran; Morteza Arab-Zozani; Meysam Behzadifar; Mehrdad Gholami; Samad Azari; Nicola Luigi Bragazzi; Masoud Behzadifar

doi:10.1371/journal.pone.0293558

. 2024 Jan 11;19(1):e0293558. doi: 10.1371/journal.pone.0293558

Overuse of computed tomography for mild head injury: A systematic review and meta-analysis

Maryam Saran ¹, Morteza Arab-Zozani ², Meysam Behzadifar ¹, Mehrdad Gholami ³, Samad Azari ⁴, Nicola Luigi Bragazzi ⁵, Masoud Behzadifar ^1,^*

Editor: Jafar Kolahi⁶

PMCID: PMC10783716 PMID: 38206917

Abstract

Background

Computed tomography (CT) scan is a common imaging technique used to evaluate the severity of a head injury. The overuse of diagnostic interventions in the health system is a growing concern worldwide.

Objectives: The aim of this systematic review is to investigate the rate of CT scan overuse in cases of mild head injury.

Methods

Eligibility criteria: We encompassed observational studies—either designed as cohort, case-control, or cross-sectional investigations—that reported on CT scan overuse rates for mild head injuries. Studies had to be published in peer-reviewed, English-language sources and provide full content access

Information sources: Web of Sciences, Scopus, Medline via PubMed, the Cochrane Library and Embase were searched from inception until April 1, 2023. Studies were included if reporting the overuse of CT scans for mild head injuries using validated criteria.

Risk of bias: We used the Risk Of Bias In Non-randomised Studies ‐ of Interventions (ROBINS-I) tool to evaluate the risk bias assessment of included studies. Two independent reviewers evaluated the eligibility of studies, extracted data, and assessed study quality by using the Newcastle-Ottawa Scale.

Synthesis of results: Overuse estimates were calculated using a random-effects model. Subgroup analyses were performed to investigate any sources of heterogeneity. Point rate of overuse of CT scans for mild head injuries was the main outcome measured as percentage point estimates with corresponding 95% CIs.

Results

Included studies: Of the 913 potentially relevant studies identified, eight studies were selected for the final analysis.

Synthesis of results: The pooled rate of CT scan overuse in patients with mild head injury was found to be 27% [95% CI: 16–43; I² = 99%]. The rate of CT scan overuse in mild head injury cases varied depending on the criteria used. The rate of CT scan overuse was 37% [95% CI: 32–42; I² = 0%] with the Glasgow Coma Scale (GCS), 30% [95% CI: 16–49; I² = 99%] with the Canadian computed tomography head rule, and 10% [95% CI: 8–14; I² = 0%] with the Pediatric Emergency Care Applied Research Network criterion (PERCAN). Based on subgroup analyses, the rate of CT scan overuse in mild head injury cases was observed to be 30% with the Canadian computed tomography head rule criterion, 43% with the National Institute for Health and Clinical Excellence criterion, and 18% with the New Orleans criterion.

Conclusion

Limitations of evidence: The restricted number of included studies may impact generalizability. High heterogeneity was observed, leading to subgroup analyses based on age, assessment criteria, and study region. Absent data on overuse causes hinders drawing conclusions on contributing factors. Furthermore, this study solely addressed overuse rates, not associated harm or benefits.

Interpretation: The overuse of CT scans in mild head injury patients is concerning, as it can result in unnecessary radiation exposure and higher healthcare costs. Clinicians and policymakers should prioritize the implementation of guidelines to reduce unnecessary radiation exposure, healthcare costs, and potential harm to patients.

Trial registration

The study protocol of this review was registered in PROSPERO under the identification code CRD42023416080. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023416080.

Introduction

Mild head injury is a common type of injury that affects the brain. It occurs when a blow or jolt to the head causes the brain to move back and forth rapidly, resulting in a disruption of normal brain function [1]. While mild head injury is typically not life-threatening, it can cause a wide range of physical, cognitive, and emotional symptoms that can last for days, weeks, or even months [2].

Computed tomography (CT) scan is a common imaging technique used to evaluate head injuries, especially in cases of mild head injuries [3,4]. It helps identify structural damages like bleeding or swelling, which could be life-threatening if not promptly treated [5]. CT scans also aid in determining the severity of the injury and guiding the appropriate management plan [6]. However, it is essential to exercise clinical judgment and consider individual circumstances, as CT scans may not always be necessary for mild head injuries without loss of consciousness or concerning symptoms [7,8]. Yet, for severe symptoms or injuries from high-impact activities, a CT scan is typically recommended to rule out underlying structural damage [9,10].

The overuse of diagnostic interventions in the health system is a growing concern worldwide [11]. The widespread use of diagnostic interventions such as CT scans, magnetic resonance imaging (MRI), and other imaging techniques, can result in unnecessary healthcare spending and increase the risk of harm to patients [12]. Overuse can also lead to a false sense of security and delay the proper diagnosis and treatment of patients who actually require these interventions [13]. Overuse of diagnostic interventions is not only a problem in developed countries, but it is also an issue in low- and middle-income countries where resources are limited [14]. In these settings, limited access to diagnostic interventions can result in healthcare providers relying on clinical judgment and physical examination to make a diagnosis [15,16]. However, the lack of access to diagnostic interventions can also result in healthcare providers relying on guesswork or assumptions, which can lead to misdiagnosis and delayed treatment. Overuse of CT in cases of mild head injury is a significant concern as it can lead to unnecessary exposure to radiation and an increase in healthcare costs [11]. The aim of this systematic review is to investigate the rate of CT scan overuse in cases of mild head injury. The findings of this study will facilitate enhanced adherence to guidelines and may assist in the development and implementation of revised treatment protocols.

Objectives

The overuse of CT scans in cases of mild head injuries in healthcare systems can lead to unnecessary expenses and potential harm to patients. The study aims to raise awareness about the evidence-based and judicious use of imaging techniques, emphasizing the importance of understanding the prevalence of CT scan overuse in mild head injuries in order to improve clinical decision-making. By implementing evidence-based guidelines, patient safety can be enhanced, avoiding unnecessary radiation exposure, and reducing false positives or overdiagnosis. The systematic review will provide insights into healthcare providers’ adherence to existing guidelines, helping develop revised treatment protocols aligned with evidence-based practices. The investigation can address potential diagnostic delays in cases where CT scans are genuinely necessary, ensuring timely treatment and better patient outcomes. Despite the importance of appropriate imaging in mild head injuries, comprehensive studies on global CT scan overuse prevalence are lacking.

This review and meta-analysis aims to fill this knowledge gap by synthesizing evidence from various countries, making a valuable contribution to the field’s literature.

Methods

This study is reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses statement (PRISMA) (S1 and S2 Tables) [17].

Eligibility criteria

Inclusion Criteria

The inclusion criteria were as follows:

Study Design: We considered observational studies, including cohort studies, case-control studies, and cross-sectional studies, which reported on the prevalence or rates of overuse of CT scans for mild head injuries.
Publication Source: Studies had to be published in peer-reviewed, scholarly journals.
Language: Only studies published in the English language were included to facilitate data extraction and analysis.
Availability: Studies had to have their entire content available, either as open-access publications or through institutional access, to ensure unrestricted access to relevant data.

Exclusion Criteria:

The exclusion criteria were as follows:

Incomplete Data: Studies lacking complete data to estimate the overall rate of CT overuse were excluded from our analysis. We aimed to include studies with sufficient information for meaningful knowledge synthesis and meta-analysis.
Review Articles: Studies that were published as review articles were excluded from our analysis to avoid duplicated data already presented elsewhere and to focus on original research.
Limited Availability: Studies without full-text availability were excluded to ensure proper evaluation of their methodology and results.
Conference Abstracts: We did not consider conference abstracts, as they often lack sufficient detail for comprehensive analysis and are more prone to selection bias. Even if, on the one hand, we recognize the importance of considering valuable information from gray literature sources, to ensure a comprehensive review of the literature, on the other hand, this may compromise the quality of our review. As such, we decided not to conduct a supplementary search specifically targeting gray literature. This search would have allowed us to have access to potentially relevant studies that might not have been captured in the peer-reviewed journal databases. The process of searching for gray literature, indeed, involves utilizing various platforms and databases, such as institutional repositories, conference websites, and relevant government databases. However, gray literature may lack quality and relevance to our research topic.
Unpublished Manuscripts: Unpublished manuscripts were excluded to maintain the integrity and verifiability of the included studies.
Interventional Studies: Studies with an intervention-based design were excluded, as our focus was on observational studies that reflected real-world clinical practices and trends.

Information sources

Search strategy

We conducted a systematic search for relevant studies through electronic databases including Web of Sciences, Scopus, Medline via PubMed, the Cochrane Library, and Embase. The search was limited to articles published from inception until April 1, 2023, and involved combining specific terms such as "prevalence," "overuse, “rate", and "mild head injury." Two teams (MS, MG, and MAZ, MeB), each consisting of two researchers, conducted the searches independently, and any discrepancies were resolved through discussion. In addition, we examined the reference lists of identified articles and used Google Scholar. There were no geographic restrictions applied to the search. (The search strategies used for each database can be found in S3 Table).

Data collection process and data items

Following the selection of relevant articles, two authors (NLB, SA) extracted information, including the first author’s name, publication year, country, criteria for diagnosing acute head injury, number of participants, age range or average, gender (number of male/female subjects), criteria for CT scan performance, and prevalence of overuse. Conflicting results were resolved by a senior (MS) researcher, and if disagreements persisted, a third reviewer (MaB) was introduced to reach a consensus. Data collection followed a form approved and designed by the authors’ group (MAZ, MeB, and MG). In instances where data was incomplete or the full text was unavailable, we contacted the corresponding author.

Study risk of bias assessment

We used the “Risk Of Bias In Non-randomised Studies ‐ of Interventions” (ROBINS-I) tool to evaluate the risk bias assessment of included studies in our assessment [18]. The following domains were examined with this tool: (1) bias resulting from confounding factors, (2) bias in participant selection for the study, (3) bias in the categorization of interventions, (4) bias due to deviations from the intended interventions, (5) bias resulting from missing data, (6) bias in the measurement of outcomes, and (7) bias in the selection of reported results. Two authors (MS, NLB) performed this assessment independently, and a third author (MaB) resolved potential disagreements.

Quality assessment of included studies

Quality assessment was assessed for each study using the Newcastle-Ottawa Scale (NOS), with any discrepancies among authors resolved through consensus. The Newcastle–Ottawa scale is a tool used for assessing the quality of non-randomized studies. Studies were categorized based on their NOS score, with scores of 1–3 indicating high quality, scores of 4–6 indicating moderate quality, and scores of 7–9 indicating low quality [19]. Two authors (SA, MG) performed this activity independently, and a third author (MS) resolved disagreements between them.

Synthesis methods

We used the R software Version 4.2.3 utilizing the meta package to perform the meta-analysis. The random-effects model was used to calculate the pooled rate, with the DerSimonian-Laird approach applied to compute 95% Confidence Intervals (CI). Heterogeneity among studies was assessed using the I² statistic. We used Baujat plot to explore heterogeneity. To assess the impact of each study, sensitivity analysis was conducted by omitting each study sequentially. Additionally, to ensure the credibility of the sensitivity analysis outcomes, a cumulative meta-analysis was performed to examine the impact of study order. We used a qualitative assessment to assess publication bias. We visually inspected the funnel plot and employed Egger’s test to quantitatively confirm the presence of small-study effects. As publication bias was identified, we utilized Duval and Tweedie’s non-parametric/trim and fill method to adjust the combined estimate. Two-sided P values were statistically significant at less than 0.05.

Results

Study selection

We identified 913 records initially, and after duplicate removal, 532 records were sought for screening. We screened the titles and abstracts of these articles and excluded 479 records. Then, we evaluated the full text of the remaining 53 records for eligibility, and 45 were excluded. Finally, we included 8 studies in our analysis, as shown in Fig 1 [20–27].

Fig 1 — Of the 913 potentially relevant studies identified, eight studies were selected for the final analysis.

Study characteristics

Summary characteristics of the included studies, involving a total of 3605 participants, are shown in Table 1.

Table 1. The characteristics of the selected studies.

First author (Reference)	Year	Country	Criteria for CT scan performance	Mean age	Male (%)	Female (%)	Sample size
Melnick [20]	2012	USA	CCHR	48	215 (62.1)	131(37.9)	346
Zargar Balaye Jame [21]	2014	Iran	Glasgow Coma Scale	36.9 ± 19.6	228 (57)	172 (43)	400
Klang [22]	2016	Israel	CCHR	69.4±21.8	428 (44.82)	527 (55.18)	955
Cellina [23]	2018	Italy	CCHR	32 ± 3	NA	NA	493
Tan [24]	2018	Singapore	CCHR	48	218 (62.4)	131 (37.6)	349
Gariepy [25]	2019	Canada	PECARN	NA	240 (59.11)	166 (40.89)	406
Shobeirian [26]	2020	Iran	CCHR	38.38 ± 19.73	NA	NA	170
Al Omran [27]	2023	Bahrain	CCHR	44.86 ± 21.609	331 (68.1)	155 (31.9)	486

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(CCHR: Canadian Computed Tomography Head Rule, PECARN: The Pediatric Emergency Care Applied Research Network, NA: Not applicable).

Quality assessment

One study [24] received a score of 6, two studies [21,22] scored 7, four studies [23,25–27] scored 8, and one study [20] scored 9. Of these, 12.5% of the studies were found to have a moderate risk of bias, and 87.5% were to have a low risk of bias (S4 Table).

Risk of bias

Fig 2 shows the summary of bias risk assessment for the studies included in the analysis. For bias related to confounding and bias in participant selection, all studies demonstrated low risk. Regarding bias in the classification of interventions, one study exhibited low risk, six studies had uncertain risk, and one study showed high risk. As for bias due to deviations from intended interventions, four studies had low risk, three studies had unclear risk, and one study had high risk. For bias stemming from missing data and bias in outcome measurement, six studies showed low risk, and two studies had unclear risk. Finally, concerning bias in the selection of reported results, seven studies displayed low risk, while one study had unclear risk.

Synthesis of results

The overall rate of CT overuse in mild head injury was estimated to be 27% [95% CI: 16–43; I² = 99%]. The rate of CT overuse in mild head injury, as determined by the physician’s decision criteria in the emergency unit used for patient evaluation, is displayed in Fig 3. The results indicate that the rate of CT overuse in mild head injury was 37% [95% CI: 32:42; I² = 0%] using the Glasgow Coma Scale (GCS), 30% [95% CI: 16:49; I² = 99%] using the Canadian Computed Tomography Head Rule (CCHR) criterion, and 10% [95% CI: 8:14; I² = 0%] using the Pediatric Emergency Care Applied Research Network (PECARN) criterion.

Fig 3 — Random effects model is used for analysis (95% confidence interval). The overall rate of CT overuse in mild head injury was estimated to be 27% [95% CI: 16–43; I² = 99%].

Due to the substantial amount of heterogeneity observed among the studies, Baujat plot was drawn (Fig 4). This visual representation demonstrates that most studies had similar rates of overuse, but the Cellina study [23] had notably a higher rate compared to the others. When we excluded this study from our analysis, the overuse rate was estimated to be 22% [95% CI: 15–32; I² = 98%].

The sensitivity and cumulative analysis

To ensure the robustness of the sensitivity analysis, the consistency of the impact of each study was assessed before and after its removal from the analysis (Fig 5). Furthermore, the effect of study order was examined through cumulative meta-analysis. The result of these two analyses showed that the rate of CT overuse in mild head injury was 27% [95% CI: 16–43; I² = 99%], (Fig 6).

Fig 5 — In this analysis, each study is excluded and in its absence, the impact on the rate amount is evaluated. This analysis showed that the results did not change and the of CT overuse in mild head injury was estimated to be 27% [95% CI: 16–43].

Fig 6 — The result of this analysis showed that the rate of CT overuse in mild head injury was 27% [95% CI: 16–43].

Subgroup analysis

The rate of CT overuse in mild head injury patients was 36% [95% CI: 3–92; I² = 100%] in Europe, 27% [95% CI: 20–36; I² = 91%] in Asia, and 20% [95% CI: 5–53; I² = 98%] in America. Additionally, the rate of CT overuse in mild head injury patients was 36% [95% CI: 14–66; I² = 99%] in individuals aged 40 years and below, and 20% [95% CI: 13–30; I² = 92%] in those above 40 years. Compliance with clinical decision rules to use CT, in cases of mild head injury the rate of CT overuse was observed to be 30% [95% CI: 16: 49] in the CCHR, 43% [95% CI: 13: 80] in the National Institute for Health and Clinical Excellence (NICE), and 18% [95% CI: 5:45] in the New Orleans Criteria (NOC). (S1–S6 Figs). The rate of CT Overuse of scan in patients with mild head injury was 35% [95% CI: 30:40] in America, 35% [95% CI: 30:40] in Iran, 23% [95% CI: 19:27] in Bahrain, 20% [95% CI: 16:25] in Singapore, 11% [95% CI: 9:13] in Israel, and 10% [95% CI: 8:14] in Canada.

Publication bias

In this study, we assessed the publication bias by visually inspection of the funnel plot and conducting the Egger’s test, which helps detect small-study effects (Fig 7). The funnel plot exhibits asymmetry, and the presence of publication bias was not statistically significant: using Egger’s test for small-study effects did not reach significance, as the bias coefficient was 16.76 [95% CI: [-7.09: 40.62] and the P-value 0.136. Also, we used Duval and Tweedie non-parametric trim and fill method. The adjusted rate from the trim and fill method did not show any significant difference compared to the unadjusted pooled rate estimates (rate = 27% [95% CI: 16–43; I² = 99%]).

Fig 7 — The funnel plot exhibits asymmetry, and the presence of publication bias was not statistically significant: using Egger’s test for small-study effects did not reach significance, as the bias coefficient was 16.76 [95% CI: [-7.09: 40.62] and the P-value 0.136.

Discussion

This study aimed to investigate the rate of overuse of CT scans in patients with mild head injury. Our findings showed that the estimated rate of overuse was 27%. It is important to note that differences in study populations, including age, gender, comorbidities, and severity of head injury, may have influenced the rate of overuse observed in our study. Moreover, differences in study design, data collection, and analysis methods may be due to variations in healthcare systems, access to imaging technologies, insurance coverage, and physician practices [11]. Furthermore, our study found that the rate of overuse of CT scans varied between countries, which may reflect differences in healthcare policies and guidelines. This highlights the need for further investigation and the development of standardized guidelines to promote the appropriate use of CT scans in patients with mild head injury.

Our study findings revealed that the highest rate of CT scans ordered in the emergency department was based on the GCS criteria, accounting for 37% of cases. One possible explanation for this high rate is that some physicians may be overly cautious or risk-averse, leading to unnecessary CT scans being ordered [28]. Another contributing factor could be the lack of clear guidelines or standardized protocols for managing mild head injuries, resulting in wide variation in the use of CT scans among different healthcare providers [29]. This can lead to inconsistencies in clinical decision-making and may contribute to overuse [27]. It is crucial to address these issues and promote the appropriate use of CT scans to avoid unnecessary radiation exposure and reduce healthcare costs [30]. The development and implementation of evidence-based guidelines and protocols for managing mild head injuries could help standardize clinical practice and promote more appropriate use of CT scans [31]. Additionally, education and training for healthcare providers on the appropriate use of imaging and the risks of overuse may also be beneficial [32].

Our study also found that the highest rate of overuse according to clinical decision rules for CT scans was observed in the NICE guidelines, accounting for 43%. NICE guidelines are widely used in the UK, and their recommendations are considered evidence-based and authoritative [30]. Therefore, the high rate of overuse observed in these settings may indicate the need to reevaluate or revise the guidelines. One possible explanation for the high rate of overuse in NICE guidelines is that they may be overly cautious in recommending CT scans for patients with mild head injury [33]. The guidelines may not consider individual risk factors or clinical characteristics that may require further imaging, leading to a general recommendation for CT scanning for all patients with mild head injury [34]. Another potential factor contributing to differences in rate estimates is the use of different criteria to diagnose mild head injury in different studies [28,33,35]. This can result in differences in patient selection and ultimately the prevalence of overuse observed in each study. Furthermore, it is important to note that different countries may have different guidelines for the use of CT scans in mild head injury patients, leading to variations in practice patterns and rate estimates [36]. Therefore, it is crucial to develop evidence-based guidelines and protocols that consider individual risk factors and clinical characteristics to promote the appropriate use of CT scans in patients with mild head injury [25].

The rate of overuse was higher in CCHR than in NOC. One possible explanation for the higher rate of overuse in the CCHR is that the rule may be more sensitive but less specific in identifying patients who require CT scans [27]. The CCHR may include more criteria for ordering CT scans, leading to a higher rate of overuse, whereas the NOC may be more specific in identifying patients who require imaging, resulting in a lower rate of overuse which is consistent with the findings of the study of Stiell et al [28]. Another potential explanation for the difference in overuse between the CCHR and NOC could be due to differences in the populations in which the rules were developed and validated [37]. The CCHR was developed and validated in a Canadian population, whereas the NOC was developed and validated in a US population [24]. These populations may differ in terms of demographics, healthcare access, and other factors that may influence the rate of overuse of CT scans [26].

There exists a diverse array of decision rules recommended for triaging CT scans in this patient group, each one balancing varying sensitivities and specificities to detect serious injuries while minimizing the number of unnecessary CT scans. Moreover, certain decision rules have specific inclusion criteria, such as excluding anti-coagulated patients or being limited to those seeking medical attention within a specific timeframe after the injury. Additionally, patients with concurrent cognitive impairment pose unique challenges in applying decision rules due to chronically impaired GCS scores, leading to differences in clinical decision-making regarding the necessity of imaging. It is essential to acknowledge the regional variation in the adoption of these decision rules, with the USA adopting a more liberal approach to CT imaging compared to the UK, where NICE guidelines are recommended. However, it should be emphasized that the contextual nature of overuse warrants attention, as even in the absence of guideline indications for imaging, certain situations may still warrant appropriate use of CT scans. In settings with limited CT imaging availability, triaging based on GCS alone might be considered, although this approach may not be clinically appropriate in resource-rich settings based in North America and Europe. Thus, our discussion highlights the significance of understanding the nuances surrounding overuse and inappropriate CT imaging in mild head injuries, emphasizing the importance of context-specific decision-making and the need for further research to establish more tailored guidelines for different healthcare settings.

The study investigated the rate of CT overuse in mild head injury patients based on age groups. The results revealed that individuals aged 40 years and below had a higher rate of CT overuse (36%) compared to those above 40 years (20%). Older patients may present with different symptoms or comorbidities that make clinicians less likely to order a CT scan for mild head injury [38]. Older patients may have a history of previous head injury, which may influence the decision-making process for ordering a CT scan [36]. Additionally, older patients may have more chronic health conditions or take medications that increase the risk of bleeding or other complications from a CT scan, leading clinicians to be more selective in their use of imaging. It is possible that older patients may have a lower threshold for accepting or declining a CT scan compared to younger patients [28]. Older patients may be more likely to have concerns about radiation exposure or other risks associated with CT scans, and may therefore be more hesitant to undergo unnecessary imaging [39]. Another possible explanation could be related to differences in the decision-making process among healthcare providers. Younger patients may be evaluated by healthcare providers who are more comfortable with clinical assessments, such as physical exams and history-taking, and may be less likely to order CT scans unless absolutely necessary [40]. In contrast, healthcare providers who evaluate older patients may be more cautious and tend to order more imaging studies due to concerns about potential complications.

Patient or family pressure, fear of litigation, and limited access to alternative diagnostic methods, such as MRI or ultrasound, are recognized factors that can contribute to the overuse of CT scans [6]. Furthermore, some emergency departments may lack the necessary resources, such as trained personnel or suitable equipment, to perform alternative diagnostic tests, leading to an over-reliance on CT scans as the primary diagnostic tool [35]. These factors may have contributed to the high rate of CT scan overuse observed in our study. To address the overuse of diagnostic interventions, healthcare providers must adopt evidence-based clinical guidelines and prioritize the appropriate use of diagnostic interventions based on each patient’s individual circumstances [38]. This approach can help reduce unnecessary testing, limit the potential for harm, and improve patient outcomes. Healthcare providers must also engage in shared decision-making with patients to ensure that the risks and benefits of any diagnostic intervention are fully discussed and understood [30]. By doing so, patients can make informed decisions about their healthcare, and healthcare providers can ensure that they are providing high-quality care that is tailored to each patient’s individual needs [25]. Healthcare systems must work to incentivize appropriate use of diagnostic interventions by promoting value-based care and implementing policies that discourage the overuse of diagnostic interventions.

There are several policies and strategies that can be implemented to reduce the overuse of CT scans in patients with mild head injuries:

Use validated clinical decision rules: Clinical decision rules such as the CCHR and NOC can help clinicians identify patients who are at low risk of intracranial injury and can safely forego CT scanning.
Attend training courses: Educating clinicians and patients about the risks and benefits of CT scans, and the potential harms of unnecessary radiation exposure, can help reduce overuse. This can include promoting the use of alternative imaging modalities or observation periods for patients who are at low risk of intracranial injury.
Develop local guidelines and protocols: Developing local guidelines and protocols can help standardize practice and reduce variations in the use of CT scans. This can include establishing clear criteria for CT scans, such as indications for imaging, the timing of scans, and follow-up plans.
Implement decision support tools: Decision support tools such as electronic medical record alerts and computerized clinical decision support systems can help remind clinicians about appropriate imaging indications and provide real-time feedback on imaging requests.
Implement audit and feedback mechanisms: Regularly auditing imaging requests and providing feedback to clinicians can help identify areas of overuse and opportunities for improvement.
Increase access to alternative imaging modalities: Increasing access to alternative imaging modalities such as MRI or ultrasound can provide clinicians with additional tools to evaluate patients with mild head injuries and reduce the reliance on CT scans.
Encourage shared decision-making: Shared decision-making between clinicians and patients can help ensure that patients are fully informed about the risks and benefits of CT scans, and that their preferences and values are taken into account when making imaging decisions.
Develop quality improvement initiatives: Quality improvement initiatives, such as team-based approaches to care and multidisciplinary care teams, can help reduce overuse of CT scans by improving communication and collaboration between healthcare providers.
Foster a culture of appropriate, responsible imaging: Establishing a culture of appropriate imaging within healthcare organizations can help promote responsible use of imaging technologies, make health systems more sustainable, and encourage clinicians to prioritize patient-centered care over unnecessary testing.

Strengths and limitations

The strength of our meta-analysis lies in its global investigation of CT scan overuse specifically in patients with mild acute head injuries, a topic that has not been previously explored in the literature. To the best of our knowledge, this is the first study to evaluate the overuse of CT scans in mild head injuries in the world. Also, the comprehensive search of different databases was one of the strengths of this study.

There are several possible limitations of this manuscript that should be considered. Firstly, the limited number of studies included in the final analysis may affect the generalizability of the findings. Secondly, another shortcoming is given by the high heterogeneity observed in the included studies. To investigate possible sources of heterogeneity across studies, we performed subgroup analysis based on subjects’ age, patient assessment criteria, and study geographic region. Additionally, the lack of data on the possible causes of the high rate of overuse limits our ability to draw conclusions regarding the underlying factors contributing to this issue. Finally, it is important to note that this study focused specifically on the rate of overuse of CT scans for mild head injury and did not evaluate the potential harm or benefits associated with this practice.

Conclusion

The rate of overuse of CT scans in mild head injury patients is rather high, with a computed figure of 27%. This suggests that there is a need for greater awareness and education among healthcare providers about appropriate imaging strategies Furthermore, efforts should be made to implement evidence-based guidelines that recommend the use of CT scans only in select cases, to reduce unnecessary exposure to radiation and optimize healthcare resource utilization.

Protocol and registration

The study protocol of this review was registered in PROSPERO under the identification code CRD42023416080 [41].

Supporting information

S1 Fig. The overuse of computed tomography for mild head injury according to the region.

Random effects model used for analysis (95% confidence interval). The rate of CT overuse in mild head injury patients was 36% [95% CI: 3–92; I² = 100%] in Europe, 27% [95% CI: 20–36; I² = 91%] in Asia, and 20% [95% CI: 5–53; I² = 98%] in America.

(DOCX)

Click here for additional data file.^{(258.1KB, docx)}

S2 Fig. The overuse of computed tomography for mild head injury according to age.

Random effects model used for analysis (95% confidence interval). The rate of CT overuse in mild head injury patients was 36% [95% CI: 14–66; I² = 99%] in individuals aged 40 years and below, and 20% [95% CI: 13–30; I² = 92%] in those above 40 years.

(DOCX)

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S3 Fig. The overuse of computed tomography for mild head injury by the Canadian computed tomography Head Rule (CCHR).

Random effects model used for analysis (95% confidence interval). The overall rate of CT overuse in mild head injury according to the CCHR was estimated to be 30% [95% CI: 16–49; I² = 99%].

(DOCX)

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S4 Fig. The overuse of computed tomography for mild head injury by the National Institute for Health and Clinical Excellence (NICE).

Random effects model used for analysis (95% confidence interval). The overall rate of CT overuse in mild head injury according to the NICE was estimated to be 43% [95% CI: 13–80; I² = 99%].

(DOCX)

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S5 Fig. The overuse of computed tomography for mild head injury by the New Orleans Criterion (NOC).

Random effects model used for analysis (95% confidence interval). The overall rate of CT overuse in mild head injury according to the NOC was estimated to be 18% [95% CI: 5–18; I² = 97%].

(DOCX)

Click here for additional data file.^{(98.1KB, docx)}

S6 Fig. The overuse of computed tomography for mild head injury based on country.

Random effects model used for analysis (95% confidence interval). The rate of CT Overuse of scan in patients with mild head injury was 35% [95% CI: 30:40] in America, 35% [95% CI: 30:40] in Iran, 23% [95% CI: 19:27] in Bahrain, 20% [95% CI: 16:25] in Singapore, 11% [95% CI: 9:13] in Israel and 10% [95% CI: 8:14] in Canada.

(DOCX)

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S1 Table. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist.

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S2 Table. PRISMA 2020 for abstracts checklist.

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S3 Table. The search strategy.

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S4 Table. Quality assessment of the included studies using the Newcastle-Ottawa Scale (NOS).

(DOCX)

Click here for additional data file.^{(15.4KB, docx)}

Abbreviations

CT: Computed tomography
MRI: Magnetic resonance imaging
LMICs: Low- and middle-income countries
PRISMA: Preferred Reporting Items for Systematic Review and Meta-Analyses statement
NOS: Newcastle-Ottawa Scale
CI: Confidence intervals
GCS: Glasgow Coma Scale
CCHR: Canadian computed tomography Head Rule
PECARN: Pediatric Emergency Care Applied Research Network
NICE: National Institute for Health and Clinical Excellence
NOC: New Orleans Criteria
RD: Risk Difference

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

The author(s) received no specific funding for this work.

References

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PLoS One. doi: 10.1371/journal.pone.0293558.r001

Decision Letter 0

Jafar Kolahi

12 Jul 2023

PONE-D-23-17711Overuse of computed tomography for mild head injury: a systematic review and meta-analysisPLOS ONE

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Please take note of the following corrections:

1. Perform a risk of bias assessment and present the results in a 'bias graph'.

2. Conduct a publication bias analysis and present the results in a 'funnel plot'.

3. Apply the trim-and-fill method to estimate potentially missing studies due to publication bias in the funnel plot and adjust the overall effect estimate accordingly.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

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Reviewer #2: Yes

Reviewer #3: Partly

**********

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**********

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Reviewer #3: Yes

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Reviewer #1: Dear authors,

The present study is a systematic review and meta-analysis on the overuse of CT scanning in mild head trauma. I appreciate the authors’ efforts for conducting this review on such an interesting and important topic. I find the manuscript generally well-written. But based on my review, there are some issues that need to be revised and addressed:

- There are several grammatical errors and typos throughout your manuscript. The manuscript may benefit from English editing by a native user.

- Quality assessment and risk of bias assessment are two separate concepts.

- Some abbreviations in the text are not necessary: LMIC

- Please elaborate further on the justification of your study.

- A brief literature review is missing.

- Inclusion and exclusion criteria need revision.

Reviewer #2: Thank you for the opportunity to review this well conducted and thorough systematic review which addresses an important clinical issue—use of CT imaging in mild traumatic brain injury.

My main concern is how overuse or inappropriate CT imaging in this group can be defined. There are a range of decision rules which can be/are recommended to be used to triage CT imaging in this group. They all balance differing sensitivities and specificities (i.e. the risk of missing a serious injury against the number of negative CT scans need to identify a rare injury) and have different inclusion criteria (e.g. the CCHR excludes anti-coagulated patients and NICE guidelines is not applicable to patient attending > 24 hours after injury). There are also patients with concurrent cognitive impairment where application of a decision rule is difficult due to chronically impaired GCS and clinical decision-making re need for imaging may differ.

Based on this different decision rules are recommended for use in different settings and the USA has a more liberal approach to CT imaging than the UK where the NICE guidelines are recommended. In North America and Europe triage of CT imaging based on GCS alone would not be clinically appropriate but this may be acceptable in other setting with more limited availability of CT imaging.

I think this nuance needs to be brought out in the discussion as over use is contextual and even where there is no guideline indication for imaging it still may be appropriate.

Reviewer #3: The manuscript entitle “Overuse of computed tomography for mild head injury: a systematic review and meta-analysis” was interesting and showed a high rate of using CT for a mild head injury, hence it might be useful for policymakers (developing guideline). However; many revisions should be done, particularly in the method and the result parts. Please see the attached file.

**********

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Reviewer #1: No

Reviewer #2: Yes: Carl Marincowitz

Reviewer #3: No

**********

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Attachment

Submitted filename: Review.docx

Click here for additional data file.^{(21.5KB, docx)}

PLoS One. 2024 Jan 11;19(1):e0293558. doi: 10.1371/journal.pone.0293558.r002

Author response to Decision Letter 0

14 Aug 2023

Dear editor

I wanted to take a moment to express my sincere gratitude for your valuable comments and feedback on my manuscript for the journal. Your thoughtful and constructive input has helped to significantly improve the quality and clarity of the manuscript. I appreciate the time and effort that you put into reviewing the manuscript and providing such insightful comments. As you may be aware, we have carefully considered your feedback and have provided responses to each of the comments raised by the reviewers. Your expertise and attention to detail have been invaluable in helping to shape the final version of the manuscript. We hope that the revised manuscript meets the required standards and addresses all of your concerns.

Thank you once again for your dedication to the peer review process and for your contributions to the advancement of scientific knowledge.

Sincerely,

Dr. Masoud Behzadifar

=======================

Additional Editor Comments:

Please take note of the following corrections:

1. Perform a risk of bias assessment and present the results in a 'bias graph'. Thank you so much for your comment. We resvised and done.

2. Conduct a publication bias analysis and present the results in a 'funnel plot'. Thank you so much for your comment. We resvised and done. 3. Apply the trim-and-fill method to estimate potentially missing studies due to publication bias in the funnel plot and adjust the overall effect estimate accordingly. Thank you so much for your comment. We resvised and done.

Reviewer #1: Dear authors,

- There are several grammatical errors and typos throughout your manuscript. The manuscript may benefit from English editing by a native user. Thank you so much for your comment. We resvised and done.

- Quality assessment and risk of bias assessment are two separate concepts. Thank you so much for your comment. We resvised and done.

- Some abbreviations in the text are not necessary: LMIC. Thank you so much for your comment. We resvised and done.

- Please elaborate further on the justification of your study. Thank you so much for your comment. We resvised and done.

- Inclusion and exclusion criteria need revision. Thank you so much for your comment. We resvised and done.

Reviewer #2: Thank you for the opportunity to review this well conducted and thorough systematic review which addresses an important clinical issue—use of CT imaging in mild traumatic brain injury.

I think this nuance needs to be brought out in the discussion as over use is contextual and even where there is no guideline indication for imaging it still may be appropriate. Thank you so much for your comment. We resvised and done.

The manuscript entitle “Overuse of computed tomography for mild head injury: a systematic review and meta-analysis” was interesting and showed a high rate of using CT for a mild head injury, hence it might be useful for policymakers (developing guideline). However; many revisions should be done, particularly in the method and the result parts.

Title: -

Abstract

1. Write it according to PRISMA 2020 for Abstracts Checklist (many revision are needed). Thank you so much for your comment. We write abstract according PRISMA 2020.

2. Apply the other comments of text, if applicable. Thank you so much for your comment. We resvised and done.

Keywords

1. Write it based on MeSH. Thank you so much for your comment. We resvised keywords based MeSH.

Introduction

1. This part was lengthy and needs some revision. Thank you so much for your comment. We shorten it.

Introduction, 2nd paragraph

1. The authors wrote about the management and consequence of the trauma. While the main aim of the study was the diagnosis. Delete it. Thank you so much for your comment. We deleted.

Introduction, 3rd and 4th paragraphs

1. Mix these paragraphs and summarize them. Thank you so much for your comment. We mixed paragraphs.

Introduction, 5th paragraphs

“as reported in studies conducted across different countries” in the aim part: I think this issue was not the main aim of your studies. Indeed, there were no subgroups regarding the region. Thank you so much for your comment. We analyzed based region and added in the text.

Method

This part needs many revisions and responses. See the comments, please.

1. Certainty (quality) of evidence should conduct. Thank you so much for your comment. We revised and done.

2. A table of findings should be added. Thank you so much for your comment. We added.

Protocol and Registration

1. Any deviation should mention here. For example: review question#2: “What is the pooled prevalence of computed tomography overuse for mild head injury based on region?” I did not find any subgroup regarding the region. Thank you so much for your comment. We analyzed based region and added in the text.

Study Design:

1. I could not find the design of study in this paragraph. Thank you so much for your comment. We deleted this phrase.

2. For PRISMA 2020 Checklist, you should report the page in the checklist in the supplementary file. Thank you so much for your comment. We added number pages.

3. Add the PRISMA 2020 for Abstracts Checklist in the supplementary file too. Thank you so much for your comment. We added PRISMA for abstract in the supplementary.

Search Strategy and Selection Criteria

1. Why did the author set a time limitation (January 2000)? Thank you so much for your comment. We revised in text (from inception until April 1, 2023).

2. Add the page of the appendix. Thank you so much for your comment. We added number pages

3. “two team”. Add the initial name of the researchers. Thank you so much for your comment. We added.

4. “to find additional studies”. Delete it. Thank you so much for your comment. We deleted.

5. "studies were published in peer-reviewed journals" was one of the inclusion criteria. Please explain that, while you should have considered the published article, you searched gray literature. More details should be added around gray literature. Thank you so much for your comment. We revised.

Eligibility Criteria

1. When some data were missed/ full texts were unavailable, it should be supposed to contact the corresponding author. Please explain why the author did not contact the corresponding authors. Thank you so much for your comment. We did this case and added in text.

2. “those published as reviews”. Delete it. Previously it was mentioned that the observational study designs were included. Thank you so much for your comment. We deleted.

3. It is unclear whether the authors consider or not considered unpublished records. Thank you so much for your comment. We added.

4. “intervention studies, or studies in languages other than English.” The type and language limitations were mentioned, previously. Thank you so much for your comment. We deleted.

Data Collection

1. “two author teams extracted information”. Add the initial name of the researchers. Thank you so much for your comment. We added.

2. Gender ratio or number? Thank you so much for your comment. We added number.

3. “criteria for CT scan performance, and prevalence of overuse”. I could not find these variables in the table. Thank you so much for your comment. We dded in Table 1.

4. “resolved by a senior researcher”. Add the initial name of the researchers. Thank you so much for your comment. We added.

5. “a third reviewer was introduced”. Add the initial name of the researcher. Thank you so much for your comment. We added.

6. “designed by the authors' group”. All authors or some of them (if some, add the initial name of them). Thank you so much for your comment. We added.

Risk of Bias of Individual Studies

7. How many authors did that? Add the initial name of them. Thank you so much for your comment. We added.

Statistical Analysis

8. "inverse variance" and "Dersimonian-Laird" are two different models. Why did the authors use two different computations? Thank you so much for your comment. We cahnged.

1. Why you did not conduct a sensitivity analysis by omitting high RoB studies? What was the benefit of conducting a RoB assessment? Thank you so much for your comment. We cahnged this section.

2. mean of age. Thank you so much for your comment.We changed.

3. I recommend conducting quantitative publication measurement (Regression-based Egger/Harbord/Peters test). In addition, funnel plots could be add in supplementary file. Thank you so much for your comment. We added and changed.

Results

1. Many revisions are needed.

Study Selection

1. “and 45 were excluded.” According to PRISMA checklist 2020, 16b: Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded. Hence, cite the articles and explain the reason for the exclusion in a table in the supplementary file. Thank you so much for your comment. We added in the supplementary file.

2. “Figure 1”. Use PRISMA 2020 flow diagram for new systematic. Thank you so much for your comment. We changed based PRISMA 2020 flow diagram.

Study Characteristics

9. “Out of a total of 8 articles, two were done in Iran. The rest of the countries had assigned one article each, and”. Delete it. Thank you so much for your comment. We deleted.

10. Add more details regard the “criteria for CT scan performance” and “criteria for diagnosing acute head injury”. Thank you so much for your comment. All patients had mild acute head injury.

Risk of Bias

11. The visualization cloud makes this part easier for the reader. Thank you so much for your comment. We added figures in the text.

12. More details are needed: for example, which domain was high risk among the studies? Add results for each study and each domain. Thank you so much for your comment. We added.

13. “The risk of bias of the included studies was assessed through the use of the NOS checklist.” Delete it. Thank you so much for your comment. We deleted..

1. “One study received a score of 6, two studies scored 7, four studies scored 8,” Cite the studies. Thank you so much for your comment. We added cite.

Synthesis of Results

1. “using a random model”. Delete it. Thank you so much for your comment. We deleted.

2. Write the I2 in the bracket and delete “This was observed with I2=99%”. Hence, the correct from is [95% CI: 16-43; I2=99%]. Thank you so much for your comment. We deleted and corrected.

3. “Figure 2”. Delete this figure. Figure 3 was enough. Thank you so much for your comment. We changed.

4. “To ensure the robustness of the sensitivity analysis, the impact of each study was consistent before and after the analysis. Furthermore, the effect of study order was examined through cumulative meta-analysis.” Here, you should report the result here. Thank you so much for your comment. We done this comment.

5. “Here, you should report the result here”. In the method part, any subgroup should be mentioned. Thank you so much for your comment. We done this comment.

6. Add I2 when reporting 95% CI. Thank you so much for your comment. We done this comment.

7. “Accordance clinical decision rules”. In the method part, any subgroup should be mentioned. These variables are also not reported in data extraction table 1. Thank you so much for your comment. We done this comment.

Comparison of criteria used in included studies

8. This part was not clear. In addition, neither declare in the aim nor method part. I think it should be deleted. Thank you so much for your comment. We deleted.

Meta-regression (last paragraph of result)

1. “This part was not clear. In addition, neither declare in the aim nor method part. I think it should be deleted.” Delete it. Thank you so much for your comment. We deleted.

2. “The results are presented in Table 2”. The results of meta-regression are presented in Table Thank you so much for your comment. We deleted.

Discussion

1. Some parts of the discussion should reassess after the method and result revisions.

Discussion, 1st paragraph

1. “However, the rate range reported in the 8 studies included in the final analysis varied.” Delete it. Thank you so much for your comment. We deleted.

2. “It is important to note that differences in study populations, including age, gender, comorbidities, and severity of head injury, may have influenced the rate of overuse observed in our study”. Some of these variables were available in your studies and could be checked (or checked) through mete-regression to support your discussion. Thank you so much for your comment. We deleyed the meta-regression based reviewer comment.

3. “Furthermore, our study found that the rate of overuse of CT scans varied between countries,” you could do a subgroup based on country to support your discussion. Thank you so much for your comment. We analyzed base country and added in the results.

Discussion, 2nd paragraph

1. “Glasgow Coma Scale (GCS)”. Delete “Glasgow Coma Scale”. Previously you define this abbreviation. Thank you so much for your comment. We deleted.

Discussion, 3rd paragraph: -

Discussion, 4th paragraph

1. It needs to reassess after revision or the author's response.

Discussion, 5th paragraph

1. First line, “our study found that”. Delete it. Thank you so much for your comment. We deleted.

Discussion, 6th paragraph: -

Discussion, 7th paragraph

1. This part (policies were suggested) was a good point of this study.

Strengths and Limitations

1. Add more strength regarding the work. Thank you so much for your comment. We added and changed.

2. How did the authors deal with heterogeneity? Thank you so much for your comment. We used subgroup analysis.

Conclusion

1. “Based on the findings of our meta-analysis, it can be concluded that”. Delete it. Thank you so much for your comment. We deleted.

2. “for mild head injury patients”. Delete it. Thank you so much for your comment. We deleted.

3. “Future research should aim to identify barriers and facilitators to the implementation of such guidelines, and to evaluate the impact of interventions aimed at reducing excessive CT scan use in mild head injury patients.” Delete it. Thank you so much for your comment. We deleted.

Data Availability

1. Data relevant to the meta-analysis were not in the supplementary file. Thank you so much for your comment. We added file.

Abbreviations

1. “CI: confidence intervals”. Write it as “CI: Confidence intervals”. Check all words. Thank you so much for your comment. We checked and revised.

Funding

1. “The author(s) received no financial support for the research, authorship, and/or publication of this article.” In CRD, Lorestan University of Medical Sciences was mentioned for funding. Transparency is very important for each study. Thank you so much for your comment. We changed this in the CRD.

Author Contributions

2. Some authors were added to the paper while their names were not in the CRD protocol. I recommend, if any deviation from protocol was done, revise the protocol in CRD. Thank you so much for your comment. We changed this in the CRD.

3. While the authors declare "no funding", what were they mean by mentioning resources?. Thank you so much for your comment. We changed this in the CRD.

References:-

Table 1

1. In “First author” column: Delete the initial names. Thank you so much for your comment. We deleted.

2. “Glasgow coma scale”. Write it “Glasgow Coma Scale”. Thank you so much for your comment. We revised.

3. “Age”. Add the value of this variable. Thank you so much for your comment. We revised.

4. “NA”. Define the NA in the footnote. Thank you so much for your comment. We revised.

5. “the Pediatric Emergency Care Applied Research Network (PECARN)” in footnote: write as “PECARN: the Pediatric Emergency Care Applied Research Network”. Thank you so much for your comment. We revised.

Table 2: -

Figure 1

6. Use PRISMA 2020 flow diagram. Thank you so much for your comment. We revised.

7. What was the difference between the two last lines in excluded box? Thank you so much for your comment. We revised.

Figure 2

8. Delete this figure. Figure 3 was enough. Thank you so much for your comment. We deleted.

Figure 3.

1. Delete the initial names. Thank you so much for your comment. We deleted.

Figure 4, 5 and 6

1. As previously mentioned, this part (Comparison of criteria used in included studies) was not clear. Thank you so much for your comment. We deleted.

Supporting Information

Search strategy

1. Add “PRESS Guideline — Search Submission & Peer Review Assessment”

PRISMA Checklist

9. For PRISMA 2020 Checklist, you should report the page in the checklist in the supplementary file. Thank you so much for your comment. We revised.

10. Add the PRISMA 2020 for Abstracts Checklist in the supplementary file too. Thank you so much for your comment. We revised.

Attachment

Submitted filename: Response lettet to reviewers.docx

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PLoS One. doi: 10.1371/journal.pone.0293558.r003

Decision Letter 1

Jafar Kolahi

30 Aug 2023

PONE-D-23-17711R1Overuse of computed tomography for mild head injury: a systematic review and meta-analysisPLOS ONE

Dear Dr. Behzadifar,

Please submit your revised manuscript by Oct 14 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Jafar Kolahi

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Please add sensitivity test, Baujat test and related plots.

[Note: HTML markup is below. Please do not edit.]

PLoS One. 2024 Jan 11;19(1):e0293558. doi: 10.1371/journal.pone.0293558.r004

Author response to Decision Letter 1

30 Aug 2023

Dear editor

Thank you once again for your dedication to the peer review process and for your contributions to the advancement of scientific knowledge.

Sincerely,

Dr. Masoud Behzadifar

=======================

Additional Editor Comments:

Please take note of the following corrections:

Please add sensitivity test, Baujat test and related plots.

Thank you so much for your comment. We added Baujat test and sensitivity test and related plots (Figure 4 and Figure 5).

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PLoS One. doi: 10.1371/journal.pone.0293558.r005

Decision Letter 2

Jafar Kolahi

20 Sep 2023

PONE-D-23-17711R2Overuse of computed tomography for mild head injury: a systematic review and meta-analysisPLOS ONE

Dear Dr. Behzadifar,

Please submit your revised manuscript by Nov 04 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Jafar Kolahi

Academic Editor

PLOS ONE

Journal Requirements:

Additional Editor Comments:

Please add citations to the table of included articles.

[Note: HTML markup is below. Please do not edit.]

PLoS One. 2024 Jan 11;19(1):e0293558. doi: 10.1371/journal.pone.0293558.r006

Author response to Decision Letter 2

20 Sep 2023

Dear editor

Thank you once again for your dedication to the peer review process and for your contributions to the advancement of scientific knowledge.

Sincerely,

Dr. Masoud Behzadifar

=======================

Additional Editor Comments:

Please add citations to the table of included articles. Thank you so much for your comment. We added references to the table of included articles.

Attachment

Submitted filename: Response to the reviewers.docx

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PLoS One. doi: 10.1371/journal.pone.0293558.r007

Decision Letter 3

Jafar Kolahi

5 Oct 2023

PONE-D-23-17711R3Overuse of computed tomography for mild head injury: a systematic review and meta-analysisPLOS ONE

Dear Dr. Behzadifar,

Please submit your revised manuscript by Nov 19 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Jafar Kolahi

Academic Editor

PLOS ONE

Journal Requirements:

Additional Editor Comments:

Please extend figure legends.

[Note: HTML markup is below. Please do not edit.]

PLoS One. 2024 Jan 11;19(1):e0293558. doi: 10.1371/journal.pone.0293558.r008

Author response to Decision Letter 3

6 Oct 2023

Dear Dr. Jafar Kolahi

Academic Editor of the PLOS ONE

I would like to express my sincere gratitude for your time and valuable feedback on my manuscript submitted to PLOS ONE. I appreciate the thorough review of my work and the opportunity to revise it in accordance with your comments and suggestions. I have carefully considered of your comment and have made the necessary revisions to improve the quality and clarity of the manuscript. Below, I address each of your points and provide an explanation of the changes made. I believe that the revisions have significantly strengthened the manuscript and have addressed the concerns raised during the initial review. Additionally, I have taken care to ensure that the manuscript complies with the journal's guidelines and formatting requirements. Please find attached the revised manuscript, along with a marked-up version highlighting the changes made. I hope that you will find these revisions satisfactory, and they meet the standards of the PLOS ONE Journal.

With best wishes

Masoud Behzadifar

Correspondence author

**********************************************

Additional Editor Comments:

Please extend figure legends.

Thank you for your constructive feedback and your valuable suggestion to extend the figure legends in our manuscript. In response to your comment, we have revised the figure legends for all figures in the manuscript. We have expanded upon the information provided in the legends to provide more context and explanation of the key findings and elements depicted in each figure. These extended figure legends now provide a more comprehensive description of the data, methodology, and results associated with each figure.

Attachment

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PLoS One. doi: 10.1371/journal.pone.0293558.r009

Decision Letter 4

Jafar Kolahi

16 Oct 2023

Overuse of computed tomography for mild head injury: a systematic review and meta-analysis

PONE-D-23-17711R4

Dear Dr. Behzadifar,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Jafar Kolahi

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0293558.r010

Acceptance letter

Jafar Kolahi

3 Jan 2024

PONE-D-23-17711R4

PLOS ONE

Dear Dr. Behzadifar,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

* All references, tables, and figures are properly cited

* All relevant supporting information is included in the manuscript submission,

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If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps.

Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

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on behalf of

Dr. Jafar Kolahi

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Fig. The overuse of computed tomography for mild head injury according to the region.

(DOCX)

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S2 Fig. The overuse of computed tomography for mild head injury according to age.

(DOCX)

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S3 Fig. The overuse of computed tomography for mild head injury by the Canadian computed tomography Head Rule (CCHR).

Random effects model used for analysis (95% confidence interval). The overall rate of CT overuse in mild head injury according to the CCHR was estimated to be 30% [95% CI: 16–49; I² = 99%].

(DOCX)

Click here for additional data file.^{(155.3KB, docx)}

S4 Fig. The overuse of computed tomography for mild head injury by the National Institute for Health and Clinical Excellence (NICE).

Random effects model used for analysis (95% confidence interval). The overall rate of CT overuse in mild head injury according to the NICE was estimated to be 43% [95% CI: 13–80; I² = 99%].

(DOCX)

Click here for additional data file.^{(117.9KB, docx)}

S5 Fig. The overuse of computed tomography for mild head injury by the New Orleans Criterion (NOC).

Random effects model used for analysis (95% confidence interval). The overall rate of CT overuse in mild head injury according to the NOC was estimated to be 18% [95% CI: 5–18; I² = 97%].

(DOCX)

Click here for additional data file.^{(98.1KB, docx)}

S6 Fig. The overuse of computed tomography for mild head injury based on country.

(DOCX)

Click here for additional data file.^{(237.5KB, docx)}

S1 Table. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist.

(DOCX)

Click here for additional data file.^{(19.4KB, docx)}

S2 Table. PRISMA 2020 for abstracts checklist.

(DOCX)

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S3 Table. The search strategy.

(DOCX)

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S4 Table. Quality assessment of the included studies using the Newcastle-Ottawa Scale (NOS).

(DOCX)

Click here for additional data file.^{(15.4KB, docx)}

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Submitted filename: Response to the reviewers-4.docx

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Data Availability Statement

All relevant data are within the manuscript and its Supporting Information files.

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PERMALINK

Overuse of computed tomography for mild head injury: A systematic review and meta-analysis

Maryam Saran

Morteza Arab-Zozani

Meysam Behzadifar

Mehrdad Gholami

Samad Azari

Nicola Luigi Bragazzi

Masoud Behzadifar

Roles

Abstract

Background

Methods

Results

Conclusion

Trial registration

Introduction

Objectives

Methods

Eligibility criteria

Information sources

Search strategy

Data collection process and data items

Study risk of bias assessment

Quality assessment of included studies

Synthesis methods

Results

Study selection

Fig 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of the search, screen and selection of studies focusing on the overuse of computed tomography in mild head injury.

Study characteristics

Table 1. The characteristics of the selected studies.

Quality assessment

Risk of bias

Fig 2. Summary of risk of bias.

Synthesis of results

Fig 3. Forest plot showing the pooled rate of overuse of computed tomography in mild head injury based on decision criteria.

Fig 4. Assessment of heterogeneity of included studies for overuse of computed tomography in mild head injury using.

The sensitivity and cumulative analysis

Fig 5. Forest plot of assessment the effect of excluding or including retained studies using sensitivity analysis.

Fig 6. Forest plot to assess trends in rate of overuse of computed tomography in mild head injury changes over time using cumulative analysis.

Subgroup analysis

Publication bias

Fig 7. Funnel plot for the assessment of publication bias among different studies.

Discussion

Strengths and limitations

Conclusion

Protocol and registration

Supporting information

Abbreviations

Data Availability

Funding Statement

References

Decision Letter 0

Jafar Kolahi

Roles

Author response to Decision Letter 0

Decision Letter 1

Jafar Kolahi

Roles

Author response to Decision Letter 1

Decision Letter 2

Jafar Kolahi

Roles

Author response to Decision Letter 2

Decision Letter 3

Jafar Kolahi

Roles

Author response to Decision Letter 3

Decision Letter 4

Jafar Kolahi

Roles

Acceptance letter

Jafar Kolahi

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES