Racial and Ethnic Differences in Emergency Department Diagnostic Imaging at US Children’s Hospitals, 2016-2019 | Emergency Medicine | JAMA Network Open | JAMA Network
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    Original Investigation
    January 29, 2021

    Racial and Ethnic Differences in Emergency Department Diagnostic Imaging at US Children’s Hospitals, 2016-2019

    Author Affiliations
    • 1Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
    • 2Department of Radiology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
    • 3Children’s Hospital Association, Lenexa, Kansas
    • 4Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
    • 5Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
    • 6Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles
    • 7Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
    • 8Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
    • 9Department of Emergency Medicine, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
    • 10Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
    • 11Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
    • 12Department of Emergency Medicine, Massachusetts General Hospital, Boston
    • 13Divisions of Hospital Medicine and Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
    • 14Division of Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
    • 15Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
    JAMA Netw Open. 2021;4(1):e2033710. doi:10.1001/jamanetworkopen.2020.33710
    Key Points

    Question  Does the use of diagnostic imaging for children receiving care in US pediatric emergency departments (EDs) differ by race and ethnicity?

    Findings  This multicenter cross-sectional study of more than 13 million pediatric ED visits to 44 children’s hospitals demonstrated that non-Hispanic Black and Hispanic patients were less likely to undergo diagnostic imaging compared with non-Hispanic White patients.

    Meaning  In these findings, race and ethnicity appear to be independently associated with imaging decisions in the pediatric ED, highlighting the need to better understand and mitigate these disparities.


    Importance  Diagnostic imaging is frequently performed as part of the emergency department (ED) evaluation of children. Whether imaging patterns differ by race and ethnicity is unknown.

    Objective  To evaluate racial and ethnic differences in the performance of common ED imaging studies and to examine patterns across diagnoses.

    Design, Setting, and Participants  This cross-sectional study evaluated visits by patients younger than 18 years to 44 US children’s hospital EDs from January 1, 2016, through December 31, 2019.

    Exposures  Non-Hispanic Black and Hispanic compared with non-Hispanic White race/ethnicity.

    Main Outcomes and Measures  The primary outcome was the proportion of visits for each race/ethnicity group with at least 1 diagnostic imaging study, defined as plain radiography, computed tomography, ultrasonography, and magnetic resonance imaging. The major diagnostic categories classification system was used to examine race/ethnicity differences in imaging rates by diagnoses.

    Results  A total of 13 087 522 visits by 6 230 911 children and adolescents (mean [SD] age, 5.8 [5.2] years; 52.7% male) occurred during the study period. Diagnostic imaging was performed during 3 689 163 visits (28.2%). Imaging was performed in 33.5% of visits by non-Hispanic White patients compared with 24.1% of visits by non-Hispanic Black patients (odds ratio [OR], 0.60; 95% CI, 0.60-0.60) and 26.1% of visits by Hispanic patients (OR, 0.66; 95% CI, 0.66-0.67). Adjusting for confounders, visits by non-Hispanic Black (adjusted OR, 0.82; 95% CI, 0.82-0.83) and Hispanic (adjusted OR, 0.87; 95% CI, 0.87-0.87) patients were less likely to include any imaging study compared with visits by non-Hispanic White patients. Limiting the analysis to only visits by nonhospitalized patients, the adjusted OR for imaging was 0.79 (95% CI, 0.79-0.80) for visits by non-Hispanic Black patients and 0.84 (95% CI, 0.84-0.85) for visits by Hispanic patients. Results were consistent in analyses stratified by public and private insurance groups and did not materially differ by diagnostic category.

    Conclusions and Relevance  In this study, non-Hispanic Black and Hispanic children were less likely to receive diagnostic imaging during ED visits compared with non-Hispanic White children. Further investigation is needed to understand and mitigate these potential disparities in health care delivery and to evaluate the effect of these differential imaging patterns on patient outcomes.