Pediatric Scan Rates High Despite Risk

Yael Waknine

June 27, 2013

One quarter of children presenting with isolated headache undergo at least a single computed tomography (CT) scan, according to the results of a study published online June 24 in Pediatrics.

"Use of CT scans to diagnose pediatric headache remains high despite existing guidelines, low diagnostic yield, and high potential risk," write Andrea DeVries, PhD, from HealthCore Inc, Wilmington, Delaware, and colleagues, noting that less than 1% of pediatric brain abnormalities present with headache as the only symptom.

For the study, researchers analyzed data for 15,836 children aged 3 to 17 years who had presented 2 or more times with isolated headache. Of these participants, 4034 (26%; mean age, 11.8 years) underwent CT scans, typically (74%) within 1 month of diagnosis.

Although children treated in the emergency department (ED) were 4 times more likely to undergo CT than those treated elsewhere (odds ratio [OR], 4.4; 95% confidence interval [CI], 3.96 - 4.85; P < .001), the greatest number of cases (67.4%) were ordered by clinicians outside the ED. Neurologists were 63% less likely than other clinicians to order a scan (OR, 0.37; 95% CI, 0.31 - 0.46; P < .01).

According to Karen Frush, MD, professor of pediatrics and chief patient safety officer at Duke University School of Medicine in Durham, North Carolina, barriers to decreased CT use include ease of access and clinicians' desire to examine all possible factors, sometimes with added pressure from parents.

"CTs are readily available and easy to complete nowadays, even with small children, because the study only takes a few minutes and there is no need for sedation, as there was in the past," Dr. Frush, who was not involved in the study, told Medscape Medical News in an interview. She also noted that the findings help clinicians feel more certain of their diagnosis even if the evidence suggests the risk for structural abnormalities is low.

Lack of consensus on what constitutes low risk may also be a factor.

"Training and expertise are critical from the clinical side, and we need to have more collaborative 'appropriateness criteria' and practice guidelines," Dr. Frush emphasized, noting that recommendations developed by a society or organization are not unilaterally accepted by groups not consulted in their development.

Other curbing mechanisms suggested by Dr. Frush included the incorporation of decision support features for computerized orders, enabling cumulative radiation dose tracking in patient charts, and developing clinician reward systems based on the use of evidence-based imaging rather than overall CT use.

Dr. Frush also noted that CT use may have declined since the study data were collected in 2007 and 2008.

"There are data to suggest that [CT] utilization has decreased across all ages over the last 3 years," Dr. Frush concluded, citing factors such as the economic downturn, uncertainty surrounding the Affordable Care Act, efforts made toward medical cost containment, and increased education/awareness of accountability for radiation exposure.

The research was funded by WellPoint Inc. Two authors are employees of HealthCore Inc, an independent research organization that received funding from WellPoint Inc. Two other authors are employees of WellPoint Inc. The remaining authors and Dr. Frush have disclosed no relevant financial relationships.

Pediatrics. Published online June 24, 2013. Abstract

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