Variation in advanced imaging for pediatric patients with abdominal pain discharged from the ED

Abstract

Background Pediatric abdominal pain visits to emergency departments (ED) are common. The objectives of this study are to assess variation in imaging [ultrasound (US) ± computed tomography (CT)] and factors associated with isolated CT use. Methods This was a retrospective cohort study of ED visits for pediatric abdominal pain resulting in discharge from 16 regional EDs from 2007–2013. Primary outcome was US or CT imaging. Secondary outcome was isolated CT use. We used multivariable logistic regression to evaluate patient- and hospital-level covariates associated with imaging. Results Of the 21,152 visits, imaging was performed in 29.7%, and isolated CT in 13.4% of visits. In multivariable analysis, black patients (OR: 0.4 (95%CI: 0.4, 0.5)) and Medicaid (OR: 0.6 (95%CI: 0.5, 0.7)) had lower odds of advanced imaging compared to white patients and private insurance, respectively. General EDs were less likely to perform imaging (OR: 0.6 (95%CI: 0.5, 0.7)) compared to the pediatric ED; however, for visits with imaging, 3.5% of visits to the pediatric ED compared to 76% of those to general EDs included an isolated CT (P<0.001). Low pediatric volume (OR: 1.8 (95%CI:1.5, 2.2)) and rural (OR:1.8 (95%CI:1.3, 2.5)) EDs had higher odds of isolated CT use, compared to higher pediatric volumes and non-rural EDs, respectively. Conclusion There are racial and insurance disparities in imaging for pediatric abdominal pain. General EDs are less likely than pediatric EDs to use imaging, but more likely to use isolated CT. Strategies are needed to minimize disparities and improve the use of “ultrasound-first.”

Assessment and Treatment Recommendations for Pediatric Pain: The Influence of Patient Race, Patient Gender, and Provider Pain-Related Attitudes

“…In contrast to the literature in adults, less is known about pain disparities in children. Several pediatric studies have identified racial disparities in antibiotic prescribing [16], diagnostic imaging for abdominal pain [32], and specialist referrals [13,65]. Of the studies that have examined racial disparities in pediatric pain, the majority focused on acute pain (e.g., bone fractures, appendicitis) [17,22,45,36,44,47,53,67] with mixed results.…”

Choosing Wisely: Determining performance of unjustified imaging in a large healthcare system

“…This is far greater than that in the US, where reportedly imaging was performed in only 29.7% of the population. 47 The study most commonly performed was US, which is in stark contrast from 2005 to 2009 data presented by Bachur et al in 2012 24 where rates of CT were up to eight times higher than US alone. The rate of CT alone, which were 3.9%, or CT following US, which was 6.9%, was similar to other databases that suggest that the proportion of ED visits which include CT ranges between 11.4% in the United States and 5.9% in Ontario, Canada, and that the rate of CT among pediatric visits rose to a high of 15.4% in 2008.…”

“…With regard to using an abdominal CT scan for the purpose [20][21][22][23] of diagnosing appendicitis, multiple studies have suggested that US is the preferred technique [21][22][23][24][25] despite the persistent use of CT. 26,27 The reduction of CT use has been recommended due to the excess radiation exposure, 28,29 even suggesting an additional case of leukaemia and an additional case of brain cancer occur for every 10 000 head CT examinations performed. 30 US has been well established as providing adequate information for vast majority of cases, and for nearly all cases as the first scan.…”

“…31,32 Several attempts have been made to reduce the use of CT scans, including improved patient education 33 provider education [34][35][36] and even "Image Gently," which are guidelines for both patients and providers. 37 However, follow-up studies suggest that the CT rate has plateaued in 2014 26,27,[38][39][40] following the initial rise in correlation to the introduction of CT. 41 The purpose of this study is to demonstrate how a large database can be used to describe diagnostic imaging which are not supported by the Choosing Wisely Campaign. This study will focus on the years 2008-2017 in order to describe the risk factors associated with unnecessary diagnostic imaging.…”

<p>Chronic Noncancer Pain Management and Systemic Racism: Time to Move Toward Equal Care Standards</p>

“…47,48 Further, several studies have indicated that BIPOC patients were less likely to receive advanced diagnostic imaging compared to White patients. [49][50][51][52][53] Given these findings, it is not surprising that BIPOC patients' pain is less likely than that of White patients to be treated through rehabilitative approaches such as physical therapy [54][55][56][57][58][59] or addressed surgically. 49,[60][61][62][63][64][65][66][67][68][69] Regarding racial and ethnic disparities in adult acute postoperative pain, McDonald found that White patients received higher dosages of opioids following appendectomies than did BIPOC patients.…”