Between 1995 and 2009, the use of chest x-rays for children with asthma significantly increased in emergency departments overall, but dropped in pediatric emergency departments – findings that have implications for savings in health care costs and safety, according to Dr. Jane F. Knapp and her associates.
Citing factors that include the average cost of a chest x-ray ($370), the average time that obtaining an x-ray adds to an ED visit (27 minutes), and evidence that many children with respiratory illnesses can be treated safely and effectively without an x-ray, the authors pointed out that "reversing this trend could improve ED efficiency, decrease costs, and decrease radiation exposure." The results of the retrospective study appear in the August issue of Pediatrics (2013;132:245-52).
Dr. Jane Knapp
Dr. Knapp of Children’s Mercy Hospitals and Clinics, Kansas City, Mo., and her coauthors used national survey data on ED visits from a sample of nonfederal, general, and short-stay hospitals in the United States to compare the rates of x-ray use for three groups of children evaluated between 1995 and 2009: those with moderate to severe asthma, aged 2-18 years; children with bronchiolitis, aged 3 months to 1 year; and children with croup, aged 3 months to 6 years.
During this period, the use of x-rays did not change significantly for the groups with bronchiolitis and croup. But the use of x-rays for children with asthma increased every year, about 7% a year (OR, 1.07). Although this annual increase appears small, it added up to a 2.4-fold increase over the period of time studied, the authors said.
"...Reversing this trend could improve ED efficiency, decrease costs, and decrease radiation exposure."
In pediatric EDs specifically, the use of x-rays significantly decreased during the period studied for all three respiratory illnesses: asthma (OR, 0.44), bronchiolitis (OR, 0.37), and croup (OR, 0.34). A look at trends according to region showed that the use of x-rays in EDs for all three conditions increased significantly in the Midwest and South compared with the Northeast. In the West, use increased significantly for those with asthma and bronchiolitis only.
The increase in x-ray use among the children with asthma could not be explained by changes in the National Asthma Education and Prevention Program guidelines. The researchers speculated that some factors related to parents, patients, and physicians. They cited evidence that physicians are more likely to order antibiotics for a child or an x-ray for a respiratory illness or low back pain when parents or patients expect such measures. "Pressures on ED physicians to practice more aggressively could also be involved," they wrote.
Although the National Heart, Lung, and Blood Institute guidelines on the use of chest x-rays in children with asthma did not change during the study period, "we also believe that they do not provide the criteria that are sufficiently explicit to affect the discretionary use of x-rays," Dr Knapp and her associates said.
“As we discussed in the article, we need to understand the reasons why more x-rays are being used over time in the ED care of the child with asthma rather than less. The reasons may be multifactorial, but just as we have worked to limit the overuse of antibiotics with guidelines, parental education, and individual and system performance evaluation, we need to find ways to limit the excess radiation and cost associated with the use of x-rays," Dr. Knapp said in an interview.
There are almost 1 million ED visits per year for pediatric asthma, bronchiolitis, and croup, they noted.
The study did not receive external funding and the authors had no disclosures.
emechcatie@frontlinemedcom.com
This story was updated. 8/5/2013