Cranial Computed Tomography Use Among Children With Minor Blunt Head Trauma

Abstract

Objective: To determine if patient race/ethnicity is independently associated with cranial computed tomography (CT) use among children with minor blunt head trauma.Design: Secondary analysis of a prospective cohort study.Setting: Pediatric research network of 25 North American emergency departments.Patients: In total, 42 412 children younger than 18 years were seen within 24 hours of minor blunt head trauma. Of these, 39 717 were of documented white non-Hispanic, black non-Hispanic, or Hispanic race/ethnicity. Using a previously validated clinical prediction rule, we classified each child's risk for clinically important traumatic brain injury to describe injury severity. Because no meaningful differences in cranial CT rates were observed between children of black non-Hispanic race/ethnicity vs Hispanic race/ethnicity, we combined these 2 groups.Main Outcome Measure: Cranial CT use in the emergency department, stratified by race/ethnicity.Results: In total, 13 793 children (34.7%) underwent cranial CT. The odds of undergoing cranial CT among children with minor blunt head trauma who were at higher risk for clinically important traumatic brain injury did not differ by race/ethnicity. In adjusted analyses, children of black non-Hispanic or Hispanic race/ethnicity had lower odds of undergoing cranial CT among those who were at intermediate risk (odds ratio, 0.86; 95% CI, 0.78-0.96) or lowest risk (odds ratio, 0.72; 95% CI, 0.65-0.80) for clinically important traumatic brain injury. Regardless of risk for clinically important traumatic brain injury, parental anxiety and request was commonly cited by physicians as an important influence for ordering cranial CT in children of white non-Hispanic race/ethnicity.Conclusions: Disparities may arise from the overuse of cranial CT among patients of nonminority races/ ethnicities. Further studies should focus on explaining how medically irrelevant factors, such as patient race/ ethnicity, can affect physician decision making, resulting in exposure of children to unnecessary health care risks.

Health Literacy Affects Likelihood of Radiology Testing in the Pediatric Emergency Department

“…These findings are similar to recent studies showing decreased radiologic testing for racial minorities evaluated in the pediatric ED for mild traumatic brain injury, 7 acute appendicitis, 6 and chest pain. 9 Our findings also echo a recent study in the pediatric ED highlighting racial disparities in ordering both laboratory and radiologic testing.…”

“…6,7 Furthermore, in indeterminate cases where there is not an objective clinical decision rule available, providers may rely on provision of an adequate history and shared decision-making to determine resource utilization in the ED. Unfortunately, both providing an adequate history and shared decision-making skills are lacking in caregivers with low health literacy.…”

“…1–4 Differences in resource utilization and radiologic testing based solely on race/ethnicity (hereafter referred to as race) have been described in the pediatric emergency department (ED). 5–7 Minorities receive fewer interventions and fewer radiologic studies across multiple disease states, especially at times when the evidence supporting clinical practice is unclear. 5–7 Recent multicentered prospective studies have shown that minority pediatric ED patients with intermediate risk for both appendicitis 6 and mild traumatic brain injury 7 are less likely to receive diagnostic imaging than their white counterparts.…”

“…5–7 Minorities receive fewer interventions and fewer radiologic studies across multiple disease states, especially at times when the evidence supporting clinical practice is unclear. 5–7 Recent multicentered prospective studies have shown that minority pediatric ED patients with intermediate risk for both appendicitis 6 and mild traumatic brain injury 7 are less likely to receive diagnostic imaging than their white counterparts. In a sample across multiple disease states, minority race was associated with less radiologic testing compared with their white counterparts.…”

Patient- and Community-Level Sociodemographic Characteristics Associated with Emergency Department Visits for Childhood Injury

“…Although this study contributes to the literature suggesting greater ED utilization, testing, and higher admission rates among injured children coming from higher SES backgrounds, 21, 37, 38 further exploration into the underlying reasons for these disparities is needed. One potential explanation for these findings is that parents of children from higher SES areas may be more likely to self-refer or be referred to trauma centers for care of higher severity injuries, whereas low income families may live close to the study sites and seek care at trauma centers for minor injuries.…”