August 8, 2012 — White children with minor blunt head trauma are more likely to undergo cranial computed tomography (CT) scanning than children from minority races, according to results from a study published in the August issue of the Archives of Pediatric Adolescent Medicine. This healthcare disparity may indicate overuse for a single race, rather than underuse for others.
Risk/benefit ratios support the use of CT scans for evaluating moderate or severe head trauma, but not for minor head trauma. The study used an algorithm to select children with minor head trauma for follow-up with CT to diagnose traumatic brain injury (TBI). Criteria include whether or not the patient lost consciousness, neurological status, evidence of skull fracture, and the details of the accident.
JoAnne E. Natale, MD, PhD, from the Department of Pediatrics, University of California, Davis, and colleagues analyzed a prospective cohort study of 42,412 children younger than 18 years who were seen in emergency departments for minor blunt head trauma within the previous 24 hours. Of these patients, 39,717 were of known race (white non-Hispanic, black non-Hispanic, or Hispanic). The analysis included reasons for deciding to follow-up with CT, including nonmedical criteria such as parental anxiety or request.
Cranial CT was performed on 13,793 (34.7%) of the sample. For those children at higher risk for TBI, race/ethnicity was not a factor. However, for children at intermediate or lower risk, race-based differences emerged, with intervention equal for both nonminority groups. For intermediate risk, the odds ratio was 0.86 (95% confidence interval [CI], 0.78 - 0.96), and for those at lowest risk, the odds ratio was 0.72 (95% CI, 0.65 - 0.80).
One factor influencing greater CT use among white children was requests from anxious parents, the researchers write. For white non-Hispanic children with the lowest risk, parental request or anxiety influenced 11.5% of cases; for the lowest-risk minority children, physicians cited parent influence in 4.9% of cases.
M. Denise Dowd, MD, MPH, from the Division of Emergency and Urgent Care Services, Children's Mercy Hospital in Kansas City, Missouri, comments in an accompanying editorial that "white children appeared to get head CT scans more often than children of color when those CT scans probably were not clinically indicated."
The researchers interpret the findings to indicate overuse of head CT for majority children, rather than underuse for minority children. Studies have found that risks for brain cancer and leukemia increase with number of CT scans before age 15 years.
They conclude, "Our findings draw attention to the possibility that a potentially unnecessary intervention with known risks...is being provided disproportionately to a group of children...and that such use may be influenced by parental preferences or assumptions about such preferences."
A limitation of the study, according to both Dr. Dowd and the authors, was not considering whether race/ethnicity was a proxy for other factors, such as poverty or insurance status. However, Dr. Dowd calls the study "a wonderful hypothesis-generating piece of work in that it reveals some information about the patterns of overuse."
The authors suggest that further studies probe the clinically irrelevant factors that may influence physician decision-making, perhaps exposing children to unnecessary radiation while inflating healthcare costs.
This work was supported by a grant from the Health Resources and Services Administration’s Maternal and Child Health Bureau, Emergency Medical Services for Children, and Division of Research, Education, and Training. The Pediatric Emergency Care Applied Research Network is supported by cooperative agreements from the Health Resources and Services Administration’s Maternal and Child Health Bureau and Emergency Medical Services for Children. The authors and editorialist have disclosed no relevant financial relationships.
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