CT Scans for Children Rise, As Do Cost, Radiation Concerns

Diedtra Henderson

October 08, 2012

October 8, 2012 — The use of expensive computerized tomography (CT) by hospital emergency departments (EDs) to evaluate pediatric patients with abdominal pain rose sharply from 1998 to 2008, with no commensurate rise in the use of other imaging technologies, hospital admission, or diagnosis of appendicitis, a cross-sectional analysis indicates.

Jahan Fahimi, MD, MPH, from the Department of Emergency Medicine at the Alameda County Medical Center, Highland General Hospital, Oakland, California; Department of Emergency Medicine at the University of California, San Francisco; and School of Public Health at the University of California, Berkeley, and coauthors reported their findings online today in the journal Pediatrics.

Worries about CT use have grown as the technology has become more routinely used, with concerns that excessive radiation exposure of vulnerable young children can increase their risk for cancer later in life. Still, it can be difficult for even experienced clinicians to accurately diagnose appendicitis in young children without imaging technology, which includes plain film radiographs, ultrasound and CT scans.

Dr. Fahimi and coauthors sought to shed light on CT use trends in ED settings among children with abdominal pain, a common reason for pediatric patients to rush to the ED. The researchers relied on the National Hospital Ambulatory Medical Care Survey (NHAMCS), an annual survey of ED and outpatient visits in the US conducted by the Centers for Disease Control and Prevention. The national sample excludes federal hospitals, hospital units of institutions, and hospitals with fewer than 6 beds.

They identified 91,699 ED visits by pediatric patients from birth to age 18 between 1998 and 2008. Six percent — 5516 visits — were for abdominal pain. Most of the pediatric visitors with abdominal pain were female, and about one-half of visits were by white/non-Hispanic children. Other outcome measures remained stable over the 11-year study period.

"We did, however, identify a steep rise in CT use over the specified time period, from 0.9% in 1998 (95% confidence interval [CI]: 0 - 1.9) to 15.4% in 2008 (95% CI: 11.7 - 19.0), with P < .001 for the temporal trend. This finding remained unchanged when analyzing trends in combined CT and/or MRI use. The proportion of children obtaining an ultrasound or plain radiograph did not change significantly (P = .11 and P = .46, respectively)," Dr. Fahimi and colleagues write.

While the NHAMCS provides such granularity as patients' age, gender, race, ethnicity, and insurance status, the researchers couldn't identify the motivations for ordering CT scans or who made the request.

"This trend may represent the introduction of more routine CT scanning into the practice of pediatric emergency medicine, increased access to CT scanners, a lower threshold for CT use by emergency providers and consultants, a change in the culture or standard of care in emergency medicine, or other unseen forces," the researchers write.

Still, the trend was not uniform. The greatest increase in CT use was seen in patients aged 12 to 18 years (12.3%). Black children were half as likely as white children to receive a CT scan, both in unadjusted analyses (12.4% vs 6.2%) and adjusted analyses (odds ratio: 0.50 [95% CI, 0.31 - 0.81]).

The authors acknowledge that their analysis was limited by the data set lumping together MRI and CT use for 4 years of the study period. The cross-sectional analysis could not provide details on change of disposition, patient or provider satisfaction, or long-term risks of CT use. Another limitation was the investigators' reliance on multiple stratifications, which dampened statistical power for some analyses.

"Additional studies should focus on the current state of CT use among children, specifically with respect to clinical outcomes, costs to the medical care system, clinical decision rules to eliminate tests with low diagnostic yield, and longitudinal analysis of radiation risk," the authors conclude.

The authors disclosed no relevant financial relationships or external funding for the study.

Pediatrics. Published online October 8, 2012. Abstract