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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Partly

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: I Don't Know

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: No

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Reviewer #1: Thank you for the opportunity to review this manuscript. The proposed topic highlights several important issues concerning a subject with significant consequences for patients. I hope these comments will help the authors.

Title:

The title does not specify that this is a secondary analysis of an already published article.

Abstract:

L 136: The described outcomes does not correspond to the study's outcomes.

Introduction:

L 156: Reference 1 could be supplemented with a more recent article by Andrew I R Maas et al, "Traumatic brain injury: progress and challenges in prevention, clinical care, and research," The Lancet Neurology, 2022.

L 161: References 3 and 4 should be positioned in the previous sentence (L159).

L 169: Reference should be supplemented by Majdan et al, "Epidemiology of traumatic brain injuries in Europe: a cross-sectional analysis," The Lancet Public Health, 2016.

L 170: The publication by Mori et al, "Indications for Computed Tomography in Older Adult Patients With Minor Head Injury in the Emergency Department," Academic Emergency Medicine, 2020, is a more recent reference.

Materials and Methods:

L 182: 71 EDs participated in the original study ("Head injuries in prehospital and Emergency Department settings: a prospective multicentre cross sectional study in France" by Dubucs et al., BMC Emergency Medicine, 2024), but only 63 are included in this study. What explains the difference? Did some centers not perform CT scans?

L 187 to 191: It would be preferable to cite those that are missing. It would be interesting to have a table by ED “Type of institution” meaning a mix of tables S1 and S2.

L 211: What data were collected regarding the patient's hospital stay?

Results:

L 251: In the original study, there were 636 patients who had a CT scan, but in this article, there are 631 patients included.

L 253: According to Table 1, the number of patients without post-TBI symptoms does not correspond.

L 256: The results of the study's second objective are not sufficiently highlighted. They only appear in Figure 3. The proportions of patients who received appropriate CT scan prescriptions according to traumatic ICH risk (high and intermediate) are missing, which is the secondary objective.

L 259: What is the number of patients with unknown mechanism? This does not appear in the flow chart.

L 261: Table 1: What do the missing values for focal neurological signs, pupillary abnormalities, and basal skull fracture signs represent? Table S3 provides the same information as Table 1 but presented more relevantly; it would be preferable to exchange them.

L 264: Table S1: What are the arguments for stating that at the regional level, patient characteristics are similar? In this same table, would it be possible to add a column with the "Type of institution" variable? Furthermore, it is difficult to establish a link between heterogeneity in CT scan prescriptions at the regional level and heterogeneity in the practices of clinicians working in emergency departments

L 266: Figure 2 - the p-value does not appear on the map. The regional level lacks granularity. The type of institution by region should be displayed.

L 273: Table 2 – legend is missing

L 278: How is this correlation determined?

L 281: No p-value on the graph in Figure 3. The regional level does not facilitate reading of results because some regions included few patients (Bourgogne FC, Normandie) and strongly impact the results shown in Figure 3. Furthermore, is the proportion of appropriate head CT scan prescriptions based on the total patients admitted to the ED after ground-level fall-related minor head injury or on the proportion of head CT scan use?

Discussion :

L 296: Does the heterogeneity concern CT use among patients admitted to the ED after ground-level fall-related minor head injury? It appears that even for appropriate prescriptions, there is no correlation with ICH incidence.

L 298: "Our study also suggests that this variation may be explained by patients' characteristics." I do not understand this suggestion - CT scan prescription recommendations are based on patient characteristics.

L 301: I completely agree with you that the main problem concerns implementation science, as explained by Cabana MD et al. "Why don't physicians follow clinical practice guidelines? A framework for improvement." JAMA. 1999, or Tucker et al. "Implementation Science: Application of Evidence-Based Practice Models to Improve Healthcare Quality." Worldviews Evid Based Nurs. 2021. The regional level does not seem relevant to explain heterogeneity. It is probably more at the individual level and how each clinician balances their clinical experience with recommendations issued by scientific societies, which are two of the pillars of EBM.

L 315: A high rate of CT prescription is not associated with ICH prevalence, but is a high rate of appropriate prescriptions associated with a high rate of ICH?

L 325: Where does this appear in your results?

L 349: This statement is particularly true for elderly patients who are not prioritized for examinations like CT scans and who may have them at a distance from the trauma. This data is particularly important to highlight given the mean age of the population in this study.

Reviewer #2: This is a multicenter cross-sectional study done in France to evaluate the variations of CTH use in patients who sustained a GLF-related head injury. The secondary objective was to measure the rate of appropriate CTH orders and to identify characteristics associated with CTH orders

Major comments

1. Need clarification on this sentence in the beginning of results: "A head CT scan was performed in 409 patients (64.8%, CI95% 61.0-68.5) and a traumatic ICH was reported in 29 (4.6%, CI95% 3.1-6.5) of them." is 4.6% out of 631 patients in the study or out of 409 patients who received CT? I am reading it as ICH yield on all CTs ordered so it should be 7.1% (29/409). In addition, Table 2 is reporting ICH prevalence out of the total of 631 patients (cohort) as 7.1%, which is confusing here. Need to reconcile those percentages

2. In discussion, author concluded that : "This heterogeneity was not associated with significant

difference of traumatic ICH prevalence." This is a bit confusing. traumatic ICH is there whether a CTH is ordered or not. In other words, for patients in the cohort who did not received a CT, they might have a traumatic ICH even if they didn't get the CTH, and would still contribute to the prevalence technically but it's just not known. Should consider changing that sentence to "traumatic ICH yield." Same apply to Conclusion and implications and the rest of the paper.

3. Authors use "appropriate CTH orders" numerously throughout the paper. It is assumed that it's any CTH ordered that concordant with National Guidelines (Study design and Settings). It might be good to define what is considered appropriate or inappropriate for this study since it's not explicitly stated.

Minor comments

1. Recommend going back to review spelling and grammar for the whole paper: Line 175 "The secondary objective was to measure the

prescription rate of appropriated head CT scan and to identify patients’ and EDs characteristic"

2. Coma Glasgow Scale Score in Table 1 should say Glasgow Coma Scale Score

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Reviewer #1: No

Reviewer #2: No

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Variability in head computed tomography use for minor head injury after ground-level falls in the emergency department: a subanalysis of EPI-TC study

PONE-D-25-25181R1

Dear Dr. Dubucs,

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.

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Kind regards,

Dr. Jan Chrusciel, M.D.

Academic Editor

PLOS ONE

Additional Editor Comments:

During the final stages of proofreading, please take care to distinguish between the words "appropriated" and "appropriate". A CT-scan prescription can be "appropriate", but not "appropriated".