MDs override guidelines: Kids w/ headache often referred for CT

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Physicians are bucking the recommendations from multiple specialty societies against the use of neuroimaging for many children presenting with headaches, researchers reported in a study published June 24 in Pediatrics. Although they are common offenders, emergency room physicians aren’t the only providers who appear to be guilty of inappropriate use.

Headaches are a common complaint among pediatric patients and a frequent indication for neuroimaging, with as many as 28 percent of the 1.7 million pediatric CT scans ordered in the ED related to headache, according to Andrea DeVries, PhD, research operations director at HealthCore in Wilmington, Del.

The American Academy of Neurology published practice guidelines recommending against neuroimaging for children with headache and a normal history and neurologic exam, a recommendation endorsed by the American Academy of Pediatrics and American College of Radiology. However, research suggests fairly high utilization of CT among this patient group.

Thus, DeVries and colleagues sought to determine the extent to which practice patterns align with guidelines. They undertook a retrospective claims analysis and examined claims data for 14 commercial health plans in the U.S., focusing on children and adolescents between the ages of 3 and 17 years who had at least two distinct medical claims for headache from Jan. 1, 2007, to Dec. 31, 2008.

A total of 25 percent of the 15,836 children meeting study criteria underwent at least one CT exam during the follow-up period. Seventy-five percent of these children fell into the category of headache symptoms/unspecified; migraine was the index diagnosis for another 22 percent.

Nearly one-third of the children undergoing CT scans visited the ED. “Although ED visit was highly correlated with CT use, it is important to note that two-thirds of the patients receiving CT scans had no ED visits at all during the study period,” wrote DeVries et al.

Children who received care from a family physician were more likely to undergo CT (odds ratio: 1.2), and those who visited a neurologist had a lower likelihood (odds ratio: 0.37).

“The widespread CT utilization across physician specialties may be due to misperceptions of the clinical benefits and risks of CT scan for diagnosis of headache or to misinterpretation by the physicians of the expectations of children and their parents,” DeVries and colleagues wrote.

The researchers suggested discrepancies in practice patterns may represent potential overuse or inappropriate use. “Furthermore, it suggests an opportunity exists to reduce exposure of children and adolescents to ionizing radiation by ensuring that a CT scan ordered on a child with a headache is done so only when truly indicated,” wrote DeVries et al, who added potential mechanisms include additional practice guidelines or educational programs.