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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1.
Flores  G; Committee on Pediatric Research.  Technical report—racial and ethnic disparities in the health and health care of children.   Pediatrics. 2010;125(4):e979-e1020. doi:10.1542/peds.2010-0188 PubMedGoogle ScholarCrossref
2.
Zhang  X, Bellolio  MF, Medrano-Gracia  P, Werys  K, Yang  S, Mahajan  P.  Use of natural language processing to improve predictive models for imaging utilization in children presenting to the emergency department.   BMC Med Inform Decis Mak. 2019;19(1):287. doi:10.1186/s12911-019-1006-6PubMedGoogle ScholarCrossref
3.
Pearce  MS, Salotti  JA, Little  MP,  et al.  Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study.   Lancet. 2012;380(9840):499-505. doi:10.1016/S0140-6736(12)60815-0 PubMedGoogle ScholarCrossref
4.
Gottlieb  RH, La  TC, Erturk  EN,  et al.  CT in detecting urinary tract calculi: influence on patient imaging and clinical outcomes.   Radiology. 2002;225(2):441-449. doi:10.1148/radiol.2252020101 PubMedGoogle ScholarCrossref
5.
Kocher  KE, Meurer  WJ, Desmond  JS, Nallamothu  BK.  Effect of testing and treatment on emergency department length of stay using a national database.   Acad Emerg Med. 2012;19(5):525-534. doi:10.1111/j.1553-2712.2012.01353.x PubMedGoogle ScholarCrossref
6.
Marin  JR, Rodean  J, Hall  M,  et al.  Trends in use of advanced imaging in pediatric emergency departments, 2009-2018.   JAMA Pediatr. 2020;174(9):e202209-e202210. doi:10.1001/jamapediatrics.2020.2209 PubMedGoogle ScholarCrossref
7.
Sailer  AM, van Zwam  WH, Wildberger  JE, Grutters  JPC.  Cost-effectiveness modelling in diagnostic imaging: a stepwise approach.   Eur Radiol. 2015;25(12):3629-3637. doi:10.1007/s00330-015-3770-8 PubMedGoogle ScholarCrossref
8.
Natale  JE, Joseph  JG, Rogers  AJ,  et al; PECARN (Pediatric Emergency Care Applied Research Network).  Cranial computed tomography use among children with minor blunt head trauma: association with race/ethnicity.   Arch Pediatr Adolesc Med. 2012;166(8):732-737. doi:10.1001/archpediatrics.2012.307 PubMedGoogle ScholarCrossref
9.
Natale  JE, Joseph  JG, Rogers  AJ,  et al.  Relationship of physician-identified patient race and ethnicity to use of computed tomography in pediatric blunt torso trauma.   Acad Emerg Med. 2016;23(5):584-590. doi:10.1111/acem.12943Google ScholarCrossref
10.
Horner  KB, Jones  A, Wang  L, Winger  DG, Marin  JR.  Variation in advanced imaging for pediatric patients with abdominal pain discharged from the ED.   Am J Emerg Med. 2016;34(12):2320-2325. doi:10.1016/j.ajem.2016.08.041 PubMedGoogle ScholarCrossref
11.
Santiago  J, Mansbach  JM, Chou  S-C,  et al.  Racial/ethnic differences in the presentation and management of severe bronchiolitis.   J Hosp Med. 2014;9(9):565-572. doi:10.1002/jhm.2223 PubMedGoogle ScholarCrossref
12.
Zook  HG, Payne  NR, Puumala  SE, Ziegler  KM, Kharbanda  AB.  Racial/ethnic variation in emergency department care for children with asthma.   Pediatr Emerg Care. 2019;35(3):209-215. doi:10.1097/PEC.0000000000001282 PubMedGoogle ScholarCrossref
13.
Schrager  JD, Patzer  RE, Kim  JJ,  et al.  Racial and ethnic differences in diagnostic imaging utilization during adult emergency department visits in the United States, 2005 to 2014.   J Am Coll Radiol. 2019;16(8):1036-1045. doi:10.1016/j.jacr.2019.03.002 PubMedGoogle ScholarCrossref
14.
Marin  JR, Wang  L, Winger  DG, Mannix  RC.  Variation in computed tomography imaging for pediatric injury-related emergency visits.   J Pediatr. 2015;167(4):897-904.e3. doi:10.1016/j.jpeds.2015.06.052 PubMedGoogle ScholarCrossref
15.
Rui  P, Kang  K. National Hospital Ambulatory Medical Care Survey: 2015 emergency department summary tables. Published March 15, 2015. Accessed June 1, 2020. https://www.cdc.gov/nchs/data/nhamcs/web_tables/2015_ed_web_tables.pdf
16.
Institute of Medicine.  Emergency Care for Children: Growing Pains. National Academies Press; 2007.
17.
The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. The EQUATOR Network. Published November 20, 2020. Accessed November 20, 2020. https://www.equator-network.org/reporting-guidelines/strobe/
18.
Samuels-Kalow  M, Neuman  MI, Rodean  J,  et al.  The care of adult patients in pediatric emergency departments.   Acad Pediatr. 2019;19(8):942-947. doi:10.1016/j.acap.2019.03.004 PubMedGoogle ScholarCrossref
19.
Institute of Medicine.  Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement. National Academies Press; 2009:1-287. doi:10.17226/12696
20.
Goyal  MK, Johnson  TJ, Chamberlain  JM,  et al; Pediatric Care Applied Research Network (PECARN).  Racial and ethnic differences in antibiotic use for viral illness in emergency departments.   Pediatrics. 2017;140(4):e20170203. doi:10.1542/peds.2017-0203 PubMedGoogle Scholar
21.
Anderson  RM, Davidson  PL, Baumeister  SE. Improving access to care. In: Kominski GF, ed. Changing the US Healthcare System. Jossey-Bass; 2013.
22.
Valtchinov  VI, Ip  IK, Khorasani  R,  et al.  Use of imaging in the emergency department: do individual physicians contribute to variation?   AJR Am J Roentgenol. 2019;213(3):637-643. doi:10.2214/AJR.18.21065 PubMedGoogle ScholarCrossref
23.
Moser  JW, Applegate  KE.  Imaging and insurance: do the uninsured get less imaging in emergency departments?   J Am Coll Radiol. 2012;9(1):50-57. doi:10.1016/j.jacr.2011.08.006 PubMedGoogle ScholarCrossref
24.
Payne  NR, Puumala  SE.  Racial disparities in ordering laboratory and radiology tests for pediatric patients in the emergency department.   Pediatr Emerg Care. 2013;29(5):598-606. doi:10.1097/PEC.0b013e31828e6489 PubMedGoogle ScholarCrossref
25.
Hong  R, Baumann  BM, Boudreaux  ED.  The emergency department for routine healthcare: race/ethnicity, socioeconomic status, and perceptual factors.   J Emerg Med. 2007;32(2):149-158. doi:10.1016/j.jemermed.2006.05.042 PubMedGoogle ScholarCrossref
26.
Wang  L, Haberland  C, Thurm  C, Bhattacharya  J, Park  KT.  Health outcomes in US children with abdominal pain at major emergency departments associated with race and socioeconomic status.   PLoS One. 2015;10(8):e0132758. doi:10.1371/journal.pone.0132758PubMedGoogle Scholar
27.
Lorch  SA, Silber  JH, Even-Shoshan  O, Millman  A.  Use of prolonged travel to improve pediatric risk-adjustment models.   Health Serv Res. 2009;44(2 Pt 1):519-541. doi:10.1111/j.1475-6773.2008.00940.xPubMedGoogle ScholarCrossref
28.
Gao  K, Pellerin  G, Kaminsky  L.  Predicting 30-day emergency department revisits.   Am J Manag Care. 2018;24(11):e358-e364.PubMedGoogle Scholar
29.
Huggins  C, Robinson  RD, Knowles  H,  et al.  Large observational study on risks predicting emergency department return visits and associated disposition deviations.   Clin Exp Emerg Med. 2019;6(2):144-151. doi:10.15441/ceem.18.024 PubMedGoogle ScholarCrossref
30.
Berdahl  CT, Vermeulen  MJ, Larson  DB, Schull  MJ.  Emergency department computed tomography utilization in the United States and Canada.   Ann Emerg Med. 2013;62(5):486-494.e3. doi:10.1016/j.annemergmed.2013.02.018 PubMedGoogle ScholarCrossref
31.
US Census Bureau. Census regions and divisions of the United States. Accessed December 22, 2014. https://data.census.gov/cedsci/table?t=Income%20and%20Earnings&g=0100000US.860000&tid=ACSST5Y2018.S1901&hidePreview=false
32.
Feudtner  C, Feinstein  JA, Zhong  W, Hall  M, Dai  D.  Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation.   BMC Pediatr. 2014;14(1):199. doi:10.1186/1471-2431-14-199 PubMedGoogle ScholarCrossref
33.
Averill  RF, Goldfield  N, Hughes  JS,  et al. All Patient Refined Diagnosis Related Groups (APR-DRGs), version 20.0: methodology overview. Published July 1, 2003. Accessed September 18, 2019. https://www.hcup-us.ahrq.gov/db/nation/nis/APR-DRGsV20MethodologyOverviewandBibliography.pdf
34.
Barnett  JC, Berchick  ER. Health insurance coverage in the US: 2016: current population reports. Published September 6, 2017. Accessed August 8, 2020. https://www.census.gov/content/dam/Census/library/publications/2017/demo/p60-260.pdf
35.
Zogg  CK, Scott  JW, Jiang  W, Wolf  LL, Haider  AH.  Differential access to care: the role of age, insurance, and income on race/ethnicity-related disparities in adult perforated appendix admission rates.   Surgery. 2016;160(5):1145-1154. doi:10.1016/j.surg.2016.06.002 PubMedGoogle ScholarCrossref
36.
Becker  JM, Ringle  CM, Sarstedt  M, Volckner  F.  How collinearity affects mixture regression results.   Marketing Lett. 2014;26(4):643-659. doi:10.1007/s11002-014-9299-9 Google ScholarCrossref
37.
Kirby  JB, Kaneda  T.  Unhealthy and uninsured: exploring racial differences in health and health insurance coverage using a life table approach.   Demography. 2010;47(4):1035-1051. doi:10.1007/BF03213738 PubMedGoogle ScholarCrossref
38.
McKay  S, Parente  V.  Health disparities in the hospitalized child.   Hosp Pediatr. 2019;9(5):317-325. doi:10.1542/hpeds.2018-0223 PubMedGoogle ScholarCrossref
39.
Chamberlain  JM, Joseph  JG, Patel  KM, Pollack  MM.  Differences in severity-adjusted pediatric hospitalization rates are associated with race/ethnicity.   Pediatrics. 2007;119(6):e1319-e1324. doi:10.1542/peds.2006-2309 PubMedGoogle ScholarCrossref
40.
Puri  K, Singh  H, Denfield  SW,  et al.  Missed diagnosis of new-onset systolic heart failure at first presentation in children with no known heart disease.   J Pediatr. 2019;208:258-264.e3. doi:10.1016/j.jpeds.2018.12.029 PubMedGoogle ScholarCrossref
41.
Naiditch  JA, Lautz  TB, Daley  S, Pierce  MC, Reynolds  M.  The implications of missed opportunities to diagnose appendicitis in children.   Acad Emerg Med. 2013;20(6):592-596. doi:10.1111/acem.12144PubMedGoogle ScholarCrossref
42.
Thorpe  EL, Zuckerbraun  NS, Wolford  JE, Berger  RP.  Missed opportunities to diagnose child physical abuse.   Pediatr Emerg Care. 2014;30(11):771-776. doi:10.1097/PEC.0000000000000257 PubMedGoogle ScholarCrossref
43.
Kressin  NR, Groeneveld  PW.  Race/ethnicity and overuse of care: a systematic review.   Milbank Q. 2015;93(1):112-138. doi:10.1111/1468-0009.12107 PubMedGoogle ScholarCrossref
44.
Fahimi  J, Herring  A, Harries  A, Gonzales  R, Alter  H.  Computed tomography use among children presenting to emergency departments with abdominal pain.   Pediatrics. 2012;130(5):e1069-e1075. doi:10.1542/peds.2012-0739 PubMedGoogle ScholarCrossref
45.
Hambrook  JT, Kimball  TR, Khoury  P, Cnota  J.  Disparities exist in the emergency department evaluation of pediatric chest pain.   Congenit Heart Dis. 2010;5(3):285-291. doi:10.1111/j.1747-0803.2010.00414.x PubMedGoogle ScholarCrossref
46.
Mannix  R, Bourgeois  FT, Schutzman  SA, Bernstein  A, Lee  LK.  Neuroimaging for pediatric head trauma: do patient and hospital characteristics influence who gets imaged?   Acad Emerg Med. 2010;17(7):694-700. doi:10.1111/j.1553-2712.2010.00797.x PubMedGoogle ScholarCrossref
47.
Betancourt  JR, Green  AR, Carrillo  JE, Ananeh-Firempong  O  II.  Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care.   Public Health Rep. 2003;118(4):293-302. doi:10.1016/S0033-3549(04)50253-4PubMedGoogle ScholarCrossref
48.
Takakuwa  KM, Estepa  AT, Shofer  FS.  Knowledge and attitudes of emergency department patients regarding radiation risk of CT: effects of age, sex, race, education, insurance, body mass index, pain, and seriousness of illness.   AJR Am J Roentgenol. 2010;195(5):1151-1158. doi:10.2214/AJR.09.3847 PubMedGoogle ScholarCrossref
49.
Hampers  LC, Cha  S, Gutglass  DJ, Binns  HJ, Krug  SE.  Language barriers and resource utilization in a pediatric emergency department.   Pediatrics. 1999;103(6, pt 1):1253-1256. doi:10.1542/peds.103.6.1253 PubMedGoogle ScholarCrossref
50.
Hall  WJ, Chapman  MV, Lee  KM,  et al.  Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review.   Am J Public Health. 2015;105(12):e60-e76. doi:10.2105/AJPH.2015.302903 PubMedGoogle ScholarCrossref
51.
Johnson  TJ, Winger  DG, Hickey  RW,  et al.  Comparison of physician implicit racial bias toward adults versus children.   Acad Pediatr. 2017;17(2):120-126. doi:10.1016/j.acap.2016.08.010 PubMedGoogle ScholarCrossref
52.
Raphael  JL, Guadagnolo  BA, Beal  AC, Giardino  AP.  Racial and ethnic disparities in indicators of a primary care medical home for children.   Acad Pediatr. 2009;9(4):221-227. doi:10.1016/j.acap.2009.01.011 PubMedGoogle ScholarCrossref
53.
Owen  WF  Jr, Szczech  LA, Frankenfield  DL.  Healthcare system interventions for inequality in quality: corrective action through evidence-based medicine.   J Natl Med Assoc. 2002;94(8)(suppl):83S-91S.PubMedGoogle Scholar
54.
Trent  M, Dooley  DG, Dougé  J; Section on Adolescent Health; Council on Community Pediatrics; Committee on Adolescence.  The impact of racism on child and adolescent health.   Pediatrics. 2019;144(2):e20191765-e16. doi:10.1542/peds.2019-1765 PubMedGoogle ScholarCrossref
55.
Raman  J, Johnson  TJ, Hayes  K, Balamuth  F.  Racial differences in sepsis recognition in the emergency department.   Pediatrics. 2019;144(4):e20190348. doi:10.1542/peds.2019-0348 PubMedGoogle Scholar
56.
Sabin  JA, Greenwald  AG.  The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma.   Am J Public Health. 2012;102(5):988-995. doi:10.2105/AJPH.2011.300621 PubMedGoogle ScholarCrossref
57.
Smith  N, Iyer  RL, Langer-Gould  A,  et al.  Health plan administrative records versus birth certificate records: quality of race and ethnicity information in children.   BMC Health Serv Res. 2010;10(1):316-317. doi:10.1186/1472-6963-10-316 PubMedGoogle ScholarCrossref
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    Original Investigation
    Pediatrics
    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.

    Abstract

    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.

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