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Original Investigation
June 3, 2019

Low-Value Diagnostic Imaging Use in the Pediatric Emergency Department in the United States and Canada

Author Affiliations
  • 1Division of Pediatric Medicine, Department of Pediatrics and Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
  • 2Department of Pediatrics, Institute of Health Policy, Management & Evaluation, The University of Toronto, Toronto, Ontario, Canada
  • 3ICES, Toronto, Ontario, Canada
  • 4Children’s Hospital Association, Lenexa, Kansas
  • 5Section of Pediatric Emergency Medicine, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 6Section of Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 7Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
  • 8Division of Emergency Medicine, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
  • 9Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
  • 10Children’s Healthcare of Atlanta, Atlanta, Georgia
  • 11Division of Pediatric Emergency Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
  • 12Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
  • 13Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 14Children’s Health System of Texas, Dallas
  • 15Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
  • 16Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
  • 17Yale School of Medicine, New Haven, Connecticut
  • 18Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, Boston, Massachusetts
JAMA Pediatr. 2019;173(8):e191439. doi:10.1001/jamapediatrics.2019.1439
Key Points

Question  Are there differences in the use of diagnostic imaging between pediatric emergency departments located in the United States and Canada?

Findings  In this cohort study, overall and low-value diagnostic imaging use rates were lower in pediatric emergency departments in Ontario, Canada, than those in the United States. No differences in post–emergency department adverse outcomes were observed.

Meaning  There may be opportunities to safely reduce imaging rates in pediatric emergency departments in the United States.

Abstract

Importance  Diagnostic imaging overuse in children evaluated in emergency departments (EDs) is a potential target for reducing low-value care. Variation in practice patterns across Canada and the United States stemming from organization of care, payment structures, and medicolegal environments may lead to differences in imaging overuse between countries.

Objective  To compare overall and low-value use of diagnostic imaging across pediatric ED visits in Ontario, Canada, and the United States.

Design, Setting, and Participants  This study used administrative health databases from 4 pediatric EDs in Ontario and 26 in the United States in calendar years 2006 through 2016. Individuals 18 years and younger who were discharged from the ED, including after visits for diagnoses in which imaging is not routinely recommended (eg, asthma, bronchiolitis, abdominal pain, constipation, concussion, febrile convulsion, seizure, and headache) were included. Data analysis occurred from April 2018 to October 2018.

Exposures  Diagnostic imaging use.

Main Outcome and Measures  Overall and condition-specific low-value imaging use. Three-day and 7-day rates of hospital admission and those admissions resulting in intensive care, surgery, or in-hospital mortality were assessed as balancing measures.

Results  A total of 1 783 752 visits in Ontario and 21 807 332 visits in the United States were analyzed. Compared with visits in the United States, those in Canada had lower overall use of head computed tomography (Canada, 22 942 [1.3%] vs the United States, 753 270 [3.5%]; P < .001), abdomen computed tomography (5626 [0.3%] vs 211 018 [1.0%]; P < .001), chest radiographic imaging (208 843 [11.7%] vs 3 408 540 [15.6%]; P < .001), and abdominal radiographic imaging (77 147 [4.3%] vs 3 607 141 [16.5%]; P < .001). Low-value imaging use was lower in Canada than the United States for multiple indications, including abdominal radiographic images for constipation (absolute difference, 23.7% [95% CI, 23.2%-24.3%]) and abdominal pain (20.6% [95% CI, 20.3%-21.0%]) and head computed tomographic scans for concussion (22.9% [95% CI, 22.3%-23.4%]). Abdominal computed tomographic use for constipation and abdominal pain, although low overall, were approximately 10-fold higher in the United States (0.1% [95% CI, 0.1%-0.2%] vs 1.2% [95% CI, 1.2%-1.2%]) and abdominal pain (0.8% [95% CI, 0.7%-0.9%] vs 7.0% [95% CI, 6.9%-7.1%]). Rates of 3-day and 7-day post-ED adverse outcomes were similar.

Conclusions and Relevance  Low-value imaging rates were lower in pediatric EDs in Ontario compared with the United States, particularly those involving ionizing radiation. Lower use of imaging in Canada was not associated with higher rates of adverse outcomes, suggesting that usage may be safely reduced in the United States.

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