Low-Value Diagnostic Imaging Use in the Pediatric Emergency Department in the United States and Canada

Eyal Cohen; Jonathan Rodean; Christina Diong; Matt Hall; Stephen B. Freedman; Paul L. Aronson; Harold K. Simon; Jennifer R. Marin; Margaret Samuels-Kalow; Elizabeth R. Alpern; Rustin B. Morse; Samir S. Shah; Alon Peltz; Mark I. Neuman

doi:10.1001/jamapediatrics.2019.1439

Low-Value Diagnostic Imaging Use in the Pediatric Emergency Department in the United States and Canada

Eyal Cohen^*, Jonathan Rodean, Christina Diong, Matt Hall, Stephen B. Freedman, Paul L. Aronson, Harold K. Simon, Jennifer R. Marin, Margaret Samuels-Kalow, Elizabeth R. Alpern, Rustin B. Morse, Samir S. Shah, Alon Peltz, Mark I. Neuman

^*Corresponding author for this work

Pediatrics

Research output: Contribution to journal › Article › peer-review

35 Scopus citations

Abstract

Importance: Diagnostic imaging overuse in children evaluated in emergency departments (EDs) is a potential target for reducing low-value care. Variation in practice patterns across Canada and the United States stemming from organization of care, payment structures, and medicolegal environments may lead to differences in imaging overuse between countries. Objective: To compare overall and low-value use of diagnostic imaging across pediatric ED visits in Ontario, Canada, and the United States. Design, Setting, and Participants: This study used administrative health databases from 4 pediatric EDs in Ontario and 26 in the United States in calendar years 2006 through 2016. Individuals 18 years and younger who were discharged from the ED, including after visits for diagnoses in which imaging is not routinely recommended (eg, asthma, bronchiolitis, abdominal pain, constipation, concussion, febrile convulsion, seizure, and headache) were included. Data analysis occurred from April 2018 to October 2018. Exposures: Diagnostic imaging use. Main Outcome and Measures: Overall and condition-specific low-value imaging use. Three-day and 7-day rates of hospital admission and those admissions resulting in intensive care, surgery, or in-hospital mortality were assessed as balancing measures. Results: A total of 1783752 visits in Ontario and 21807332 visits in the United States were analyzed. Compared with visits in the United States, those in Canada had lower overall use of head computed tomography (Canada, 22942 [1.3%] vs the United States, 753270 [3.5%]; P <.001), abdomen computed tomography (5626 [0.3%] vs 211018 [1.0%]; P <.001), chest radiographic imaging (208843 [11.7%] vs 3408540 [15.6%]; P <.001), and abdominal radiographic imaging (77147 [4.3%] vs 3607141 [16.5%]; P <.001). Low-value imaging use was lower in Canada than the United States for multiple indications, including abdominal radiographic images for constipation (absolute difference, 23.7% [95% CI, 23.2%-24.3%]) and abdominal pain (20.6% [95% CI, 20.3%-21.0%]) and head computed tomographic scans for concussion (22.9% [95% CI, 22.3%-23.4%]). Abdominal computed tomographic use for constipation and abdominal pain, although low overall, were approximately 10-fold higher in the United States (0.1% [95% CI, 0.1%-0.2%] vs 1.2% [95% CI, 1.2%-1.2%]) and abdominal pain (0.8% [95% CI, 0.7%-0.9%] vs 7.0% [95% CI, 6.9%-7.1%]). Rates of 3-day and 7-day post-ED adverse outcomes were similar. Conclusions and Relevance: Low-value imaging rates were lower in pediatric EDs in Ontario compared with the United States, particularly those involving ionizing radiation. Lower use of imaging in Canada was not associated with higher rates of adverse outcomes, suggesting that usage may be safely reduced in the United States..

Original language	English (US)
Article number	e191439
Journal	JAMA Pediatrics
Volume	173
Issue number	8
DOIs	https://doi.org/10.1001/jamapediatrics.2019.1439
State	Published - Aug 2019

Funding

Funding/Support: This study was supported by the Agency for Healthcare Research and Quality (grant K08HS026006 [Dr Aronson]) and the Alberta Children’s Hospital Foundation Professorship in Child Health and Wellness (Dr Freedman). In addition, ICES is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. Parts of the data and/or information compiled were provided by the Canadian Institute for Health Information. reports grants from the National Center for Advancing Translational Sciences/National Institutes of Health (grant UL 1TR002541), during the conduct of the study. Dr Shah reports grants from the Patient-Centered Outcomes Research Institute, grants from the National Heart, Blood, and Lung Institute, grants from the National Institute of Allergy and Infectious Diseases, and personal fees from Society of Hospital Medicine outside the submitted work. No other disclosures were reported. This study was supported by the Agency for Healthcare Research and Quality (grant K08HS026006 [Dr Aronson]) and the Alberta Children's Hospital Foundation Professorship in Child Health andWellness (Dr Freedman). In addition, ICES is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. Parts of the data and/or information compiled were provided by the Canadian Institute for Health Information.

ASJC Scopus subject areas

Pediatrics, Perinatology, and Child Health

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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10.1001/jamapediatrics.2019.1439

Cite this

Cohen, E., Rodean, J., Diong, C., Hall, M., Freedman, S. B., Aronson, P. L., Simon, H. K., Marin, J. R., Samuels-Kalow, M., Alpern, E. R., Morse, R. B., Shah, S. S., Peltz, A., & Neuman, M. I. (2019). Low-Value Diagnostic Imaging Use in the Pediatric Emergency Department in the United States and Canada. JAMA Pediatrics, 173(8), Article e191439. https://doi.org/10.1001/jamapediatrics.2019.1439

@article{c53b1c65af3b40ef8963ba32248c86e4,

title = "Low-Value Diagnostic Imaging Use in the Pediatric Emergency Department in the United States and Canada",

abstract = "Importance: Diagnostic imaging overuse in children evaluated in emergency departments (EDs) is a potential target for reducing low-value care. Variation in practice patterns across Canada and the United States stemming from organization of care, payment structures, and medicolegal environments may lead to differences in imaging overuse between countries. Objective: To compare overall and low-value use of diagnostic imaging across pediatric ED visits in Ontario, Canada, and the United States. Design, Setting, and Participants: This study used administrative health databases from 4 pediatric EDs in Ontario and 26 in the United States in calendar years 2006 through 2016. Individuals 18 years and younger who were discharged from the ED, including after visits for diagnoses in which imaging is not routinely recommended (eg, asthma, bronchiolitis, abdominal pain, constipation, concussion, febrile convulsion, seizure, and headache) were included. Data analysis occurred from April 2018 to October 2018. Exposures: Diagnostic imaging use. Main Outcome and Measures: Overall and condition-specific low-value imaging use. Three-day and 7-day rates of hospital admission and those admissions resulting in intensive care, surgery, or in-hospital mortality were assessed as balancing measures. Results: A total of 1783752 visits in Ontario and 21807332 visits in the United States were analyzed. Compared with visits in the United States, those in Canada had lower overall use of head computed tomography (Canada, 22942 [1.3%] vs the United States, 753270 [3.5%]; P <.001), abdomen computed tomography (5626 [0.3%] vs 211018 [1.0%]; P <.001), chest radiographic imaging (208843 [11.7%] vs 3408540 [15.6%]; P <.001), and abdominal radiographic imaging (77147 [4.3%] vs 3607141 [16.5%]; P <.001). Low-value imaging use was lower in Canada than the United States for multiple indications, including abdominal radiographic images for constipation (absolute difference, 23.7% [95% CI, 23.2%-24.3%]) and abdominal pain (20.6% [95% CI, 20.3%-21.0%]) and head computed tomographic scans for concussion (22.9% [95% CI, 22.3%-23.4%]). Abdominal computed tomographic use for constipation and abdominal pain, although low overall, were approximately 10-fold higher in the United States (0.1% [95% CI, 0.1%-0.2%] vs 1.2% [95% CI, 1.2%-1.2%]) and abdominal pain (0.8% [95% CI, 0.7%-0.9%] vs 7.0% [95% CI, 6.9%-7.1%]). Rates of 3-day and 7-day post-ED adverse outcomes were similar. Conclusions and Relevance: Low-value imaging rates were lower in pediatric EDs in Ontario compared with the United States, particularly those involving ionizing radiation. Lower use of imaging in Canada was not associated with higher rates of adverse outcomes, suggesting that usage may be safely reduced in the United States..",

author = "Eyal Cohen and Jonathan Rodean and Christina Diong and Matt Hall and Freedman, {Stephen B.} and Aronson, {Paul L.} and Simon, {Harold K.} and Marin, {Jennifer R.} and Margaret Samuels-Kalow and Alpern, {Elizabeth R.} and Morse, {Rustin B.} and Shah, {Samir S.} and Alon Peltz and Neuman, {Mark I.}",

note = "Funding Information: Funding/Support: This study was supported by the Agency for Healthcare Research and Quality (grant K08HS026006 [Dr Aronson]) and the Alberta Children{\textquoteright}s Hospital Foundation Professorship in Child Health and Wellness (Dr Freedman). In addition, ICES is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. Parts of the data and/or information compiled were provided by the Canadian Institute for Health Information. Funding Information: reports grants from the National Center for Advancing Translational Sciences/National Institutes of Health (grant UL 1TR002541), during the conduct of the study. Dr Shah reports grants from the Patient-Centered Outcomes Research Institute, grants from the National Heart, Blood, and Lung Institute, grants from the National Institute of Allergy and Infectious Diseases, and personal fees from Society of Hospital Medicine outside the submitted work. No other disclosures were reported. Funding Information: This study was supported by the Agency for Healthcare Research and Quality (grant K08HS026006 [Dr Aronson]) and the Alberta Children's Hospital Foundation Professorship in Child Health andWellness (Dr Freedman). In addition, ICES is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. Parts of the data and/or information compiled were provided by the Canadian Institute for Health Information. Publisher Copyright: {\textcopyright} 2019 American Medical Association. All rights reserved.",

year = "2019",

month = aug,

doi = "10.1001/jamapediatrics.2019.1439",

language = "English (US)",

volume = "173",

journal = "JAMA Pediatrics",

issn = "2168-6203",

publisher = "American Medical Association",

number = "8",

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TY - JOUR

T1 - Low-Value Diagnostic Imaging Use in the Pediatric Emergency Department in the United States and Canada

AU - Cohen, Eyal

AU - Rodean, Jonathan

AU - Diong, Christina

AU - Hall, Matt

AU - Freedman, Stephen B.

AU - Aronson, Paul L.

AU - Simon, Harold K.

AU - Marin, Jennifer R.

AU - Samuels-Kalow, Margaret

AU - Alpern, Elizabeth R.

AU - Morse, Rustin B.

AU - Shah, Samir S.

AU - Peltz, Alon

AU - Neuman, Mark I.

N1 - Funding Information: Funding/Support: This study was supported by the Agency for Healthcare Research and Quality (grant K08HS026006 [Dr Aronson]) and the Alberta Children’s Hospital Foundation Professorship in Child Health and Wellness (Dr Freedman). In addition, ICES is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. Parts of the data and/or information compiled were provided by the Canadian Institute for Health Information. Funding Information: reports grants from the National Center for Advancing Translational Sciences/National Institutes of Health (grant UL 1TR002541), during the conduct of the study. Dr Shah reports grants from the Patient-Centered Outcomes Research Institute, grants from the National Heart, Blood, and Lung Institute, grants from the National Institute of Allergy and Infectious Diseases, and personal fees from Society of Hospital Medicine outside the submitted work. No other disclosures were reported. Funding Information: This study was supported by the Agency for Healthcare Research and Quality (grant K08HS026006 [Dr Aronson]) and the Alberta Children's Hospital Foundation Professorship in Child Health andWellness (Dr Freedman). In addition, ICES is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. Parts of the data and/or information compiled were provided by the Canadian Institute for Health Information. Publisher Copyright: © 2019 American Medical Association. All rights reserved.

PY - 2019/8

Y1 - 2019/8

N2 - Importance: Diagnostic imaging overuse in children evaluated in emergency departments (EDs) is a potential target for reducing low-value care. Variation in practice patterns across Canada and the United States stemming from organization of care, payment structures, and medicolegal environments may lead to differences in imaging overuse between countries. Objective: To compare overall and low-value use of diagnostic imaging across pediatric ED visits in Ontario, Canada, and the United States. Design, Setting, and Participants: This study used administrative health databases from 4 pediatric EDs in Ontario and 26 in the United States in calendar years 2006 through 2016. Individuals 18 years and younger who were discharged from the ED, including after visits for diagnoses in which imaging is not routinely recommended (eg, asthma, bronchiolitis, abdominal pain, constipation, concussion, febrile convulsion, seizure, and headache) were included. Data analysis occurred from April 2018 to October 2018. Exposures: Diagnostic imaging use. Main Outcome and Measures: Overall and condition-specific low-value imaging use. Three-day and 7-day rates of hospital admission and those admissions resulting in intensive care, surgery, or in-hospital mortality were assessed as balancing measures. Results: A total of 1783752 visits in Ontario and 21807332 visits in the United States were analyzed. Compared with visits in the United States, those in Canada had lower overall use of head computed tomography (Canada, 22942 [1.3%] vs the United States, 753270 [3.5%]; P <.001), abdomen computed tomography (5626 [0.3%] vs 211018 [1.0%]; P <.001), chest radiographic imaging (208843 [11.7%] vs 3408540 [15.6%]; P <.001), and abdominal radiographic imaging (77147 [4.3%] vs 3607141 [16.5%]; P <.001). Low-value imaging use was lower in Canada than the United States for multiple indications, including abdominal radiographic images for constipation (absolute difference, 23.7% [95% CI, 23.2%-24.3%]) and abdominal pain (20.6% [95% CI, 20.3%-21.0%]) and head computed tomographic scans for concussion (22.9% [95% CI, 22.3%-23.4%]). Abdominal computed tomographic use for constipation and abdominal pain, although low overall, were approximately 10-fold higher in the United States (0.1% [95% CI, 0.1%-0.2%] vs 1.2% [95% CI, 1.2%-1.2%]) and abdominal pain (0.8% [95% CI, 0.7%-0.9%] vs 7.0% [95% CI, 6.9%-7.1%]). Rates of 3-day and 7-day post-ED adverse outcomes were similar. Conclusions and Relevance: Low-value imaging rates were lower in pediatric EDs in Ontario compared with the United States, particularly those involving ionizing radiation. Lower use of imaging in Canada was not associated with higher rates of adverse outcomes, suggesting that usage may be safely reduced in the United States..

AB - Importance: Diagnostic imaging overuse in children evaluated in emergency departments (EDs) is a potential target for reducing low-value care. Variation in practice patterns across Canada and the United States stemming from organization of care, payment structures, and medicolegal environments may lead to differences in imaging overuse between countries. Objective: To compare overall and low-value use of diagnostic imaging across pediatric ED visits in Ontario, Canada, and the United States. Design, Setting, and Participants: This study used administrative health databases from 4 pediatric EDs in Ontario and 26 in the United States in calendar years 2006 through 2016. Individuals 18 years and younger who were discharged from the ED, including after visits for diagnoses in which imaging is not routinely recommended (eg, asthma, bronchiolitis, abdominal pain, constipation, concussion, febrile convulsion, seizure, and headache) were included. Data analysis occurred from April 2018 to October 2018. Exposures: Diagnostic imaging use. Main Outcome and Measures: Overall and condition-specific low-value imaging use. Three-day and 7-day rates of hospital admission and those admissions resulting in intensive care, surgery, or in-hospital mortality were assessed as balancing measures. Results: A total of 1783752 visits in Ontario and 21807332 visits in the United States were analyzed. Compared with visits in the United States, those in Canada had lower overall use of head computed tomography (Canada, 22942 [1.3%] vs the United States, 753270 [3.5%]; P <.001), abdomen computed tomography (5626 [0.3%] vs 211018 [1.0%]; P <.001), chest radiographic imaging (208843 [11.7%] vs 3408540 [15.6%]; P <.001), and abdominal radiographic imaging (77147 [4.3%] vs 3607141 [16.5%]; P <.001). Low-value imaging use was lower in Canada than the United States for multiple indications, including abdominal radiographic images for constipation (absolute difference, 23.7% [95% CI, 23.2%-24.3%]) and abdominal pain (20.6% [95% CI, 20.3%-21.0%]) and head computed tomographic scans for concussion (22.9% [95% CI, 22.3%-23.4%]). Abdominal computed tomographic use for constipation and abdominal pain, although low overall, were approximately 10-fold higher in the United States (0.1% [95% CI, 0.1%-0.2%] vs 1.2% [95% CI, 1.2%-1.2%]) and abdominal pain (0.8% [95% CI, 0.7%-0.9%] vs 7.0% [95% CI, 6.9%-7.1%]). Rates of 3-day and 7-day post-ED adverse outcomes were similar. Conclusions and Relevance: Low-value imaging rates were lower in pediatric EDs in Ontario compared with the United States, particularly those involving ionizing radiation. Lower use of imaging in Canada was not associated with higher rates of adverse outcomes, suggesting that usage may be safely reduced in the United States..

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Low-Value Diagnostic Imaging Use in the Pediatric Emergency Department in the United States and Canada

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