Designing a Multi-Stakeholder Collaboration to Reduce Overuse of Neuroimaging for Minor Head Injury and Atraumatic Headache

ABSTRACT OBJECTIVE Despite recommendations to limit the use of neuroimaging for evaluation of minor head injury and atraumatic headache in children, many children receive unnecessary imaging without clear history or physical exam indications in the emergency department (ED) or other outpatient settings. This overuse of neuroimaging has not previously been explored across clinical settings, nor for the diagnosis of atraumatic headache. METHODS We convened a multi-stakeholder design meeting to discuss reasons for overuse of neuroimaging in children and brainstorm potential interventions to reduce overuse. The meeting included didactic sessions on the risks and benefits of neuroimaging and quality improvement methodology. There were also small group discussions of challenges and potential interventions. RESULTS Participants included ED physicians and nurses, radiologists, Medicaid health plan representatives, a pediatric neurologist, a pediatric primary care provider and a parent. Reasons for overuse included family anxiety and expectations for neuroimaging, pediatric phone triage protocols directing patients to the ED for evaluation, time pressures within primary care and the ED clinics, and reluctance among payers to institute prior authorization for ED-based imaging studies. Several potential interventions were identified and organized into three key driver diagrams: one each for primary care, the ED, and Medicaid health plans. CONCLUSION Convening a multi-stakeholder meeting was feasible and resulted in the identification of common reasons for overuse of neuroimaging in children and many potential interventions across clinical settings. Similar multidisciplinary approaches may be helpful for others interested in reducing the overuse of imaging in children.