U.S. emergency departments have begun performing more advanced imaging on pediatric patients over the last decade, relying more on non-radiating modalities.
Researchers at UPMC Children's Hospital of Pittsburgh performed a cross-sectional evaluation of over 26 million pediatric department visits and found a more than 2% increase in the rate of advanced imaging between 2009 and 2018. Driving this rise were increases in ultrasonography and MR imaging, compared to a decrease in CT scanning.
“CT uses ionizing radiation in order to generate images,” lead author Dr. Jennifer Marin, of UPMC Children's Hospital of Pittsburgh and associate professor of pediatrics and emergency medicine at the University of Pittsburgh School of Medicine, told HCB News. “Although we don't understand the precise risks from medical radiation exposures, scientific consensus is that such radiation increases the lifetime risk of cancer. The risk is inversely proportional to patient age, meaning the risk is higher for young children compared to adults. Neither ultrasound nor MR use radiation, and therefore, we try, whenever feasible, to utilize these modalities in lieu of CT.”
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An increased awareness of radiation risks from CT has led to the development of evidence-based guidelines, improvements in imaging technology and greater availability of non-radiating modalities, all of which have potentially reduced CT use. Ultrasound imaging provides accurate information for many diagnoses that were historically made with CT. Providers are also starting to see the advantages of using "rapid" MR sequences in lieu of lengthy CT exams to make accurate diagnoses.
It is this reasoning according to Marin that has propelled utilization of ultrasonography from 2.5% to 5.8%, and the rate of MR imaging from 0.3% to 0.6% over the last 10 years. Use of CT imaging, in contrast, dropped from 3.9% to 2.9%. The largest declines in CT rates were for concussion (-23%); appendectomy (-14.9%); ventricular shunt procedures (-13.3%), and headaches (-12.4%). Increased use of ultrasonography was observed for abdominal pain (20.3%); and appendectomy (42.5%). MR was used more in ventricular shunt procedures (17.9%).
The findings were based on an evaluation of 26,082,062 visits by 9,868,406 children admitted to 32 U.S. pediatric EDs between January 2009 and December 2018. One or more advanced imaging studies were used in 1,919,283 encounters (7.4%).
The researchers also found that length of ED stays overall did not change, but hospitalization and three-day ED revisit rates decreased during the study period. EDs, however, varied widely in the use of ultrasonography for appendectomies and MR for ventricular shunt procedures, suggesting substantial variation in practice and a need to standardize imaging practices.
“When there is good evidence for the evaluation and management of certain conditions, clinicians should apply that evidence when making decisions, if it is feasible,” said Marin. “For example, there are clinical decision rules available for the evaluation of pediatric head trauma that assist clinicians in determining which children we can safely avoid performing head CTs on. In the evaluation of abdominal pain, where appendicitis is the most concerning and feared diagnosis, clinicians can apply clinical scores which will risk stratify patients and allow us to safely avoid imaging in certain patients.”
She adds, however, that choosing which test to perform depends on the resources available at the institution. “While ultrasound is the preferred initial test for many diagnoses, it may not be available at some emergency departments. Similarly, many emergency departments around the country may not have pediatric ‘rapid’ protocols and will have to rely on CT for some conditions.”
The findings were published in JAMA Pediatrics