Pediatric CT use spikes, benefits remain uncertain
Use of CT among children presenting to the emergency department (ED) with abdominal pain increased substantially from 1998 to 2008, according to a study published in the November issue of Pediatrics. The researchers also found racial disparities in CT utilization.

As CT imaging has emerged as a mainstream diagnostic tool, concerns about radiation exposure have escalated. In addition, the link between CT imaging and improved clinical outcomes among pediatric patients with abdominal pain remains unclear.

Jahan Fahimi, MD, MPH, of the department of emergency medicine at Alameda County Medical Center-Highland Hospital in Oakland, Calif., and colleagues sought to evaluate trends in CT imaging among patients newborn to 18 years presenting to the ED with abdominal pain.

The researchers mined the National Hospital Ambulatory Medical Survey for the years 1998 to 2008. Among 91,669 ED visits, 6 percent were for abdominal pain. Total visits to the ED and diagnosis of appendicitis remained stable over the 11-year study period. In contrast, utilization of CT swelled from 0.9 percent in 1998 to 15.4 percent in 2008.  

Fahimi and colleagues reported that black children were one-half as likely as white children to receive a CT scan and also found uninsured children underwent less CT imaging than privately insured children. They observed a greater magnitude of increased CT use in nonacademic and nonpediatric facilities.

The growth in CT appeared to plateau over time, as the researchers noted each subsequent year of visit was associated with increasing CT use in 1998-2000, but not in 2006-2008.

The steep rise in CT may be related to several factors, according to Fahimi et al. These include 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 or a change in culture of standard of care in emergency medicine.

The researchers partially attributed lower utilization among black and uninsured children to fewer or different resources in urban public facilities. They referred to previous research indicating that black children with appendicitis have lower overall hospitalization rates, higher rates of perforation, a greater delay to surgical management and lower laparoscopic rates. “Although the reasons for these findings are assuredly multifactorial, differential application of diagnostic testing may contribute,” Fahimi and colleagues wrote.

The increase in CT is problematic from two perspectives. It raises concerns about radiation exposure and cancer risk. “Furthermore, when considered at the population level, increased reliance on expensive technology, including radiologic testing, contributes substantially to rising healthcare costs, often with inconclusive causal benefits in terms of outcomes.”

Fahimi and colleagues wrote that the reasons for and benefits of increasing use of CT remain unclear. They suggested several avenues for future research: racial and ethnic disparities, clinical outcomes, costs, clinical decision rules to eliminate low-yield exams and longitudinal analysis of radiation risk.  

For more about pediatric CT, please read "Pediatric CT: Growing Pains," in Health Imaging.