Emergency department (ED) computed tomography (CT) imaging rates for children with nontraumatic abdominal pain have changed little since 2007, although pediatric EDs are more likely than general EDs to use the recommended ultrasound as a first imaging procedure.
Explore This IssueACEP Now: Vol 36 – No 10 – October 2017
“I believe that the dissemination of pediatric radiology protocols used in pediatric EDs to general EDs may help minimize radiation exposure in children,” Dr. Joanna S. Cohen from George Washington University, Washington, DC, told Reuters Health by email. “These protocols generally emphasize a stepwise approach to management, with ultrasound first and CT only if the diagnosis remains unclear after the ultrasound.”
Between 1999 and 2017, the use of CT for children presenting to EDs with nontraumatic abdominal pain increased from 2 percent to 16 percent, even though ultrasound-first paradigms are most cost-effective for imaging pediatric appendicitis.
Dr. Cohen’s team used the ED data set from the National Hospital Ambulatory Medical Care Survey, covering 2007 through 2014, to investigate national trends in CT and ultrasound imaging for the evaluation of nontraumatic abdominal pain among children presenting to general and pediatric EDs.
ED visit rates for these patients did not change significantly during the study period, according to the September 15 Pediatrics online report. Among the 5,036 ED visits included in the study, 14.6 percent prompted only a CT scan, 10.9 percent only an ultrasound, and 1.9 percent both tests, resulting in a final diagnosis of appendicitis in 3.7 percent of the patients. The overall rates of CT and ultrasound use for these patients did not change significantly between 2007 and 2014.
Pediatric EDs were 66 percent less likely than general EDs to use CT and 2.14-fold more likely than general EDs to use ultrasound. Pediatric and general EDs did not differ in their use of both CT and ultrasound or in their use of any imaging to assess pediatric nontraumatic abdominal pain.
“I think it’s most interesting that while we have seen a plateau in CT imaging for children with abdominal pain, it is still more likely that a child with abdominal pain evaluated in a general ED will receive a CT compared to a similar patient seen in a pediatric-specific ED,” Dr. Cohen said. “There is still more work to be done to standardize care of pediatric patients among EDs.”
“The majority of children receive emergency care in general EDs,” she said, “so optimizing radiation exposure in children really depends on collaboration with our general emergency medicine colleagues.”
Dr. Ralph Wang from University of California, San Francisco, who also recently reported a plateau in CT imaging of children with emergency visits for abdominal pain, told Reuters Health by email, “Several initiatives have been implemented to decrease inappropriate advanced imaging use, including payment reform (deficit reduction act), dissemination of research findings linking radiation from CT use to cancer, educational campaigns such as Imaging Gently/Choosing Wisely, clinical decision support in electronic health records, etc. Perhaps all of these efforts have resulted in a slowdown in imaging.”
“Despite the slowdown, inappropriate use of CT and other advanced imaging is likely to be considerable,” he said. “More evidence is needed to provide rational imaging guidelines for other clinical conditions, and these guidelines should be implemented.”
“Another piece of recently passed legislation – Protecting Access to Medicare Act (PAMA) – requires that clinicians who order advanced imaging first consult clinical decision support based on evidence-based imaging guidelines prior to ordering a study,” Dr. Wang added.