Pediatric Advanced Imaging: When Is Less More?

Pediatric Advanced Imaging: When Is Less More?

Although CT scans have declined in the past decade among pediatric patients presenting to the emergency department, advanced imaging has increased overall, according to an analysis of 32 tertiary care children’s hospitals.

Among more than 26 million emergency department (ED) visits recorded from 2009-2018, the proportion involving CT scans significantly decreased from 3.9% to 2.9% (P

Meanwhile the proportion of visits involving ultrasonography increased from 2.5% to 5.8% (PPJAMA Pediatrics.
Overall, the proportion of visits involving any form of advanced imaging increased from 6.4% to 8.7% across the 10-year study period, indicating that upwards of 60,000 more advanced imaging procedures were performed, they added.
“The [rate of] ultrasound increased more dramatically than the decrease in CT and I think there are a lot of factors at play there,” Marin told MedPage Today.
For example, physicians may feel pressured to make a timely diagnosis within an ED visit, or don’t want to risk malpractice for missing a diagnosis, Marin said.
“A family comes to the ED with their child’s symptom or condition and they’ve waited for several hours and paid a copay,” Marin said. “It can be challenging to not do a test and to ask them to do what we call ‘watchful waiting.’ As a society, we have less tolerance for that today than we have in the past.”
The “Choosing Wisely” campaigns from the American Academy of Pediatrics and the American College of Radiology launched in 2012 aimed to reduce unnecessary CT scans in children due to the downstream risk of cancer associated with ionizing radiation.
These findings are “encouraging” in terms of radiation exposure, but “less encouraging” in terms of healthcare value, as they indicate that instead of conserving resources, one test may just be replacing another, commented Alan R. Schroeder, MD, and Daniel L. Imler, MD, both of the Stanford University School of Medicine in Palo Alto, California, in an accompanying editorial.
The “potential perils” of increased imaging include incidental findings, false-positives, and overdiagnosis, Schroeder and Imler noted. In any case, the detection of an abnormality does not automatically equate to a clinical benefit, but explaining to families that screening can sometimes do more harm than good is “not easy,” they pointed out.
“In contrast to the harms associated with radiation from CT, where mention of the word cancer dampens most families’ enthusiasm for testing, the harms associated with overdiagnosis are more nuanced,” they wrote. “[A]lthough the financial strain caused by high healthcare costs has been increasingly reported, invoking costs as a reason to avoid low-value testing can be a perilous discussion.”
Although a study comparing these findings with patient outcomes is necessary to understand whether increased imaging rates are linked to improvements, in this study, there was a slight decrease in the rate of hospital admissions and 3-day ED revisits coinciding with the increased imaging rates. The increased rate of imaging was also higher in patients who were ultimately hospitalized compared with patients who were discharged.
However, “other secular trends might explain these outcomes as well,” Schroeder and Imler noted. For example, a heightened awareness of concussion in recent years is likely contributing to an increased rate of ED visits for milder injuries, they explained.
Overall, this study can “serve as a guide” to identify the most frequent conditions for which imaging is performed, but “outcomes assessments are also needed,” they wrote.
Study Details, Further Findings
For this study, researchers analyzed billing codes for advanced imaging undergone by children 18 and under in 32 hospitals in the Pediatric Health Information System (PHIS). They also looked at conditions associated with CT changes, the length of ED stay for discharged patients, hospitalization rates, and 3-day ED revisit rates.
The cohort of 9,868,406 children — 53.1% male, mean age 5.6 years — were mostly publicly insured (64.4%). About 35% were white, 27% were Black, and 29% were Hispanic. Most were discharged from the ED (86.1%).
Older kids (5 years and up), white patients, children with complex chronic conditions, and those who were privately insured all had an elevated risk of having a CT, MRI, and ultrasonography, researchers reported.
In an analysis of the rate of imaging across various all patient-refined diagnosis related groups (APR-DRGs), some conditions such as appendectomy, abdominal pain, and ventricular shunt procedures were associated with an overall increase in advanced imaging, despite reductions in CT use. Meanwhile, CT use was not associated with an increased use of other modalities for conditions like concussion, Marin and colleagues said.
Notably, the degree of variability across hospitals by imaging modality and condition was “quite striking,” and indicates there is potentially overuse and underuse in different settings, Marin said.
“It’s unlikely that patient characteristics or severity of illness would fully explain the degree of variability that we found,” Marin said. “We should really be seeing somewhat of a more uniform rate.”
Some imaging in this study may have been performed after patients were admitted to the hospital as opposed to within the ED, and physicians may have billed to a different site because of the structure of the database used, which are limitations, the researchers reported. Also, the indications for imaging as well as harms caused by imaging, such as incidental findings, were not captured, they added.

  • author['full_name']
    Elizabeth Hlavinka covers clinical news, features, and investigative pieces for MedPage Today. She also produces episodes for the Anamnesis podcast. Follow

Disclosures
A co-author reported receiving funding from the Agency for Healthcare Research and Quality, Alberta Children’s Hospital Foundation Professorship in Child Health and Wellness, the National Center for Advancing Translational Sciences, the National Institutes of Health, and Harvard University.

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