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Original Investigation
August 3, 2020

Trends in Use of Advanced Imaging in Pediatric Emergency Departments, 2009-2018

Author Affiliations
  • 1Division of Pediatric Emergency Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
  • 2Children’s Hospital Association, Lenexa, Kansas
  • 3Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 4Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
  • 5Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
  • 6Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles
  • 7Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
  • 8Alberta Children’s Hospital Research Institute, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
  • 9Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, 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, Massachusetts
  • 13Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
  • 14Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
  • 15Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
  • 16Department of Emergency Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
  • 17Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
JAMA Pediatr. 2020;174(9):e202209. doi:10.1001/jamapediatrics.2020.2209
Key Points

Question  How has the use of advanced imaging changed during the past 10 years across pediatric emergency departments in the US?

Findings  This cross-sectional study of 26 million pediatric emergency department visits revealed that, overall, the rate of advanced imaging increased from 6.4% of encounters in 2009 to 8.7% in 2018; specifically, the rate of computed tomography decreased from 3.9% to 2.9%, the rate of ultrasonography increased from 2.5% to 5.8%, and the rate of magnetic resonance imaging increased from 0.3% to 0.6%.

Meaning  Overall use of advanced imaging has increased during the past decade, driven by the use of nonradiating modalities replacing the use of computed tomography.


Importance  There is increased awareness of radiation risks from computed tomography (CT) in pediatric patients. In emergency departments (EDs), evidence-based guidelines, improvements in imaging technology, and availability of nonradiating modalities have potentially reduced CT use.

Objective  To evaluate changes over time and hospital variation in advanced imaging use.

Design, Setting, and Participants  This cross-sectional study assessed 26 082 062 ED visits by children younger than 18 years from the Pediatric Health Information System administrative database from January 1, 2009, through December 31, 2018.

Exposures  Imaging.

Main Outcomes and Measures  The primary outcome was the change in CT, ultrasonography, and magnetic resonance imaging (MRI) rates from January 1, 2009, to December 31, 2018. Imaging for specific diagnoses was examined using all patient-refined diagnosis related groups. Secondary outcomes were hospital admission and 3-day ED revisit rates and ED length of stay.

Results  There were a total of 26 082 062 visits by 9 868 406 children (mean [SD] age, 5.59 [5.15] years; 13 842 567 [53.1%] male; 9 273 181 [35.6%] non-Hispanic white) to 32 US pediatric EDs during the 10-year study period, with 1 or more advanced imaging studies used in 1 919 283 encounters (7.4%). The proportion of ED encounters with any advanced imaging increased from 6.4% (95% CI, 6.2%-6.2%) in 2009 to 8.7% (95% CI, 8.7%-8.8%) in 2018. The proportion of ED encounters with CT decreased from 3.9% (95% CI, 3.9%-3.9%) to 2.9% (95% CI, 2.9%-3.0%) (P < .001 for trend), with ultrasonography increased from 2.5% (95% CI, 2.5%-2.6%) to 5.8% (95% CI, 5.8%-5.9%) (P < .001 for trend), and with MRI increased from 0.3% (95% CI, 0.3%-0.4%) to 0.6% (95% CI, 0.6%-0.6%) (P < .001 for trend). The largest decreases in CT rates were for concussion (−23.0%), appendectomy (−14.9%), ventricular shunt procedures (−13.3%), and headaches (−12.4%). Factors associated with increased use of nonradiating imaging modalities included ultrasonography for abdominal pain (20.3%) and appendectomy (42.5%) and MRI for ventricular shunt procedures (17.9%) (P < .001 for trend). Across the study period, EDs varied widely in the use of ultrasonography for appendectomy (median, 57.5%; interquartile range [IQR], 40.4%-69.8%) and MRI (median, 15.8%; IQR, 8.3%-35.1%) and CT (median, 69.5%; IQR, 54.5%-76.4%) for ventricular shunt procedures. Overall, ED length of stay did not change, and hospitalization and 3-day ED revisit rates decreased during the study period.

Conclusions and Relevance  This study found that use of advanced imaging increased from 2009 to 2018. Although CT use decreased, this decrease was accompanied by a greater increase in the use of ultrasonography and MRI. There appears to be substantial variation in practice and a need to standardize imaging practices.

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