Abdominal X-rays Decreased in Children With Constipation

Veronica Hackethal, MD

June 14, 2017

Rates of unnecessary abdominal X-rays decreased from 62% to 24% in children seen in the emergency department (ED) for constipation after implementation of a quality improvement intervention.

The study is the first to publish results of a quality improvement project for managing constipation in the pediatric ED. The researchers report their findings in an article published online June 12 in Pediatrics.

"We significantly decreased the use of [abdominal X-rays] in the diagnosis of constipation for patients presenting to a pediatric ED by using simple, cost-efficient interventions that included provider education, metrics reporting, and academic detailing," Catherine Craun Ferguson, MD, from the Medical College of Wisconsin, Milwaukee, and colleagues write.

Constipation is a major cause of acute abdominal pain and ED visits in children. Expert consensus guidelines advise against the use of abdominal X-rays in the diagnosis of constipation, and recommend diagnosing the problem clinically. No reliable scoring system exists for diagnosing constipation on X-rays, and studies have suggested they may lead to misdiagnosis. Also, unnecessary use exposes children to potentially damaging radiation and can drive up healthcare costs.

To see how the pediatric ED at the Children's Hospital of Wisconsin was fending on this issue, researchers evaluated abdominal X-ray use during a 7-month preintervention period (November 2012-May 2013). They discovered that 63% of 800 children with low-acuity complaints who had been diagnosed with constipation in the ED had abdominal X-rays during this time.

To encourage evidence-based practices, the investigators conducted a quality improvement project, with the goal of decreasing the rate of the procedures from 60% to 20%.

The intervention took place from December 2013 to May 2014, and used four plan-do-study-act cycles during which researchers evaluated progress toward the quality improvement goal and provided additional intervention as needed. Interventions included: Grand Rounds on constipation, sharing best practices, reporting on progress toward the goal, and peer-to-peer educational outreach.

After 12 months, the mean rate of abdominal X-rays for children with constipation in the ED decreased from 62% to 24%.

Results also showed that response to the project varied by provider type, suggesting interventions such as these may need to be tailored to providers' specific needs and training.

For example, general pediatricians and advanced practice providers who cared for low-acuity patients did not change their practice behaviors as quickly as pediatric emergency medicine physicians and fellows who cared for higher-acuity patients. None of the former group attended Grand Rounds, whereas from 55% to 68% of the latter did.

After an additional intervention using emailed educational materials and peer-to-peer educational outreach by a general pediatrician who acted as a role model and provided support, abdominal X-ray rates decreased among providers who cared for lower acuity patients.

Although the study could not do a formal cost analysis, the researchers estimated that if this progress were sustained, the hospital would save about $17,500 annually.

Researchers are continuing to monitor progress. So far, the overall mean rate of abdominal X-rays remained at 24% through October 2016.

"Our next steps include working with hospital-affiliated community pediatricians to inform their [abdominal X-ray]-ordering practices for patients with constipation, and we plan to reach out to other community urgent care centers and EDs in the future," the authors conclude.

They note several limitations, including the lack of a control group. So the study cannot definitely say whether the intervention caused the decrease in abdominal X-ray rates, or whether the decrease happened for some other reason.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online June 12, 2017. Abstract

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