Use of Radiography in Patients Diagnosed as Having Acute Bronchiolitis in US Emergency Departments, 2007-2015 | Emergency Medicine | JAMA | JAMA Network
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Figure.  Weighted Proportion of Children Undergoing Radiography in US Emergency Departments for Acute Bronchiolitis by Year
Weighted Proportion of Children Undergoing Radiography in US Emergency Departments for Acute Bronchiolitis by Year

Error bars indicate 95% CIs. Mean value for 2007-2015, 46% (95% CI, 40%-53%; P for trend =.87).

Table.  Characteristics of ED Visits Among Children Younger Than 2 Years With Bronchiolitis and Association With Radiography Use, 2007-2015
Characteristics of ED Visits Among Children Younger Than 2 Years With Bronchiolitis and Association With Radiography Use, 2007-2015
1.
Kyu  HH, Pinho  C, Wagner  JA,  et al; Global Burden of Disease Pediatrics Collaboration.  Global and national burden of diseases and injuries among children and adolescents between 1990 and 2013: findings from the Global Burden of Disease 2013 Study.  JAMA Pediatr. 2016;170(3):267-287. doi:10.1001/jamapediatrics.2015.4276PubMedGoogle ScholarCrossref
2.
Ralston  SL, Lieberthal  AS, Meissner  HC,  et al; American Academy of Pediatrics.  Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis.  Pediatrics. 2014;134(5):e1474-e1502. doi:10.1542/peds.2014-2742PubMedGoogle ScholarCrossref
3.
Centers for Disease Control and Prevention.  National Ambulatory Medical Care Survey. https://www.cdc.gov/nchs/ahcd/about_ahcd.htm. Accessed November 22, 2017.
4.
Johnson  LW, Robles  J, Hudgins  A, Osburn  S, Martin  D, Thompson  A.  Management of bronchiolitis in the emergency department: impact of evidence-based guidelines?  Pediatrics. 2013;131(suppl 1):S103-S109. doi:10.1542/peds.2012-1427mPubMedGoogle ScholarCrossref
5.
Parikh  K, Hall  M, Teach  SJ.  Bronchiolitis management before and after the AAP guidelines.  Pediatrics. 2014;133(1):e1-e7. doi:10.1542/peds.2013-2005PubMedGoogle ScholarCrossref
6.
Mussman  GM, Lossius  M, Wasif  F,  et al.  Multisite emergency department inpatient collaborative to reduce unnecessary bronchiolitis care [published online January 10, 2018].  Pediatrics. 2018;141(2):e20170830. doi:10.1542/peds.2017-0830PubMedGoogle ScholarCrossref
Research Letter
October 16, 2018

Use of Radiography in Patients Diagnosed as Having Acute Bronchiolitis in US Emergency Departments, 2007-2015

Author Affiliations
  • 1Division of Pediatric Emergency Medicine, Montreal Children’s Hospital, Montreal, Quebec, Canada
  • 2Division of Emergency Medicine, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
  • 3Division of Pediatric Infectious Diseases, Montreal Children’s Hospital, Montreal, Quebec, Canada
JAMA. 2018;320(15):1598-1600. doi:10.1001/jama.2018.9245

Bronchiolitis, a viral infection of the lower respiratory tract, is an important health burden among young children worldwide1 and the most common cause of hospitalization in the first year of life in the United States.2 Clinical practice guidelines of the American Academy of Pediatrics (AAP), published in 2006 and revised in 2014, recommend against routine radiography in the evaluation of infants with bronchiolitis.2 Unnecessary imaging for bronchiolitis contributes to health care costs, radiation exposure, and antibiotic overuse and consequently was identified in 2013 as a national “Choosing Wisely” priority. In this study, a longitudinal assessment of the proportion of infants diagnosed as having bronchiolitis who received radiography in emergency departments (EDs) between 2007 and 2015 was performed.

Methods

Using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), we conducted a repeated cross-sectional analysis of ED visits in the United States from 2007 to 2015 (most recent year of data release). The NHAMCS is conducted annually by the Centers for Disease Control and Prevention National Center for Health Statistics and uses multistage probability sampling to collect data about EDs, outpatient departments, and ambulatory surgery locations in the United States. Each visit is the basic sampling unit and is assigned a weight to allow generation of nationally representative estimates.3 Our analysis was restricted to the NHAMCS ED data set (approximately 30 000 visits to 300 randomly selected US EDs) and included children younger than 2 years with an ED discharge/admitting diagnosis of bronchiolitis (as identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes 466, 466.11, and 466.19). We applied survey-weighting procedures to estimate annual frequency of radiography overall and in subgroups of admitted and discharged patients. Multivariable logistic regression was performed adjusting for patient- and ED-level covariates (STATA version 14.1; StataCorp). We analyzed trends using a Pearson χ2 test of proportions. A 2-tailed P<.05 was considered statistically significant. This study was exempted from review by the McGill University Health Centre Research Ethics Board.

Results

Between 2007 and 2015, there were 269 721 unweighted ED visits in the NHAMCS, of which 59 921 were for children younger than 18 years. Among these, 612 (1.1% [95% CI, 0.9%-1.3%]; range, 53-75 observations annually) had an ED diagnosis of bronchiolitis. Median age was 8 months (interquartile range, 5-12 months), 58.8% were male, 66.9% were white, and the majority presented to nonteaching and nonpediatric hospitals (Table). The mean proportion of patients who were diagnosed as having bronchiolitis and received radiography was 46.1% (95% CI, 39.5%-52.8%). There was no change in the proportion of infants undergoing radiography by year (P for trend =.87; Figure), as confirmed in multivariable analysis (adjusted odds ratio for effect of year, 0.99 [95% CI, 0.91-1.08]). Among ED visits, 89.7% of patients were discharged and 10.3% were admitted. Restricting analysis to ED-discharged patients similarly revealed overall radiography use of 46.2% (95% CI, 39.4%-53.2%), which did not differ from the proportion among admitted children (44.8% [95% CI, 29.2%-61.6%]; P = .83). Using multivariable analysis, higher rates of imaging were associated with nonpediatric hospitals and race identity other than black or white (Table).

Discussion

Using a large representative sample of US ED visits, no decrease in radiography was observed between 2007 and 2015, despite AAP bronchiolitis guidelines in 2006 and 2014 and Choosing Wisely recommendations in 2013. Modest downward trends in radiography use were found in studies conducted immediately following AAP guidelines4 and among admitted patients at pediatric centers.5 Assuming study visits can be projected to reflect the US population, there would have been an estimated 2.92 million pediatric ED visits for bronchiolitis over the 9-year study period. In this broad ED context, radiography was performed in nearly half of bronchiolitis cases, and more frequently at nonpediatric hospitals. These results suggest that nationwide quality initiatives are still needed to translate bronchiolitis guidelines into practice.6

Study limitations include a lack of clinical data to determine the appropriateness of radiographic imaging, which may differ depending on physician experience. However, AAP guidelines recommend imaging only in severe cases that warrant intensive care or suggest the possibility of airway complication,2 which is unlikely for ED-discharged patients. The NHAMCS does not specify body location of radiographs; chest imaging was assumed, which may have led to overestimation. The analyses relied on NHAMCS diagnosis accuracy and its rigorous validation processes to minimize misclassification.

Section Editor: Jody W. Zylke, MD, Deputy Editor.
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Article Information

Accepted for Publication: June 11, 2018.

Corresponding Author: Brett Burstein, MDCM, PhD, MPH, Division of Pediatric Emergency Medicine, Montreal Children’s Hospital, 1001 Decarie Blvd, Montreal, QC H4C 3J1, Canada (brett.burstein@mail.mcgill.ca).

Author Contributions: Dr Burstein had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Burstein, Papenburg.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Burstein.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Burstein.

Administrative, technical, or material support: Burstein.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Papenburg reports receipt of grants from BD Diagnostics, AbbVie, and MedImmune and personal fees from BD Diagnostics, Cepheid, AbbVie, and Merck outside the submitted work. No other disclosures were reported.

Funding/Support: Dr Plint is supported by a University of Ottawa Tier II Research Chair award. Dr Papenburg is supported by a Chercheur-boursier clinician career award from the Fonds de Recherche Québec Santé.

Role of the Funder/Sponsor:The career award sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Nadine Korah, MDCM, MSc (Montreal Children’s Hospital, Division of General Pediatrics), Roger Zemek, MD (Children’s Hospital of Eastern Ontario, Division of Emergency Medicine), and Erin Strumpf, PhD (McGill University, Department of Economics) for helpful discussions, and Marcel Behr, MD, MSc (McGill University Health Centre, Department of Microbiology) for editing assistance. None were compensated for their contributions.

References
1.
Kyu  HH, Pinho  C, Wagner  JA,  et al; Global Burden of Disease Pediatrics Collaboration.  Global and national burden of diseases and injuries among children and adolescents between 1990 and 2013: findings from the Global Burden of Disease 2013 Study.  JAMA Pediatr. 2016;170(3):267-287. doi:10.1001/jamapediatrics.2015.4276PubMedGoogle ScholarCrossref
2.
Ralston  SL, Lieberthal  AS, Meissner  HC,  et al; American Academy of Pediatrics.  Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis.  Pediatrics. 2014;134(5):e1474-e1502. doi:10.1542/peds.2014-2742PubMedGoogle ScholarCrossref
3.
Centers for Disease Control and Prevention.  National Ambulatory Medical Care Survey. https://www.cdc.gov/nchs/ahcd/about_ahcd.htm. Accessed November 22, 2017.
4.
Johnson  LW, Robles  J, Hudgins  A, Osburn  S, Martin  D, Thompson  A.  Management of bronchiolitis in the emergency department: impact of evidence-based guidelines?  Pediatrics. 2013;131(suppl 1):S103-S109. doi:10.1542/peds.2012-1427mPubMedGoogle ScholarCrossref
5.
Parikh  K, Hall  M, Teach  SJ.  Bronchiolitis management before and after the AAP guidelines.  Pediatrics. 2014;133(1):e1-e7. doi:10.1542/peds.2013-2005PubMedGoogle ScholarCrossref
6.
Mussman  GM, Lossius  M, Wasif  F,  et al.  Multisite emergency department inpatient collaborative to reduce unnecessary bronchiolitis care [published online January 10, 2018].  Pediatrics. 2018;141(2):e20170830. doi:10.1542/peds.2017-0830PubMedGoogle ScholarCrossref
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