Increases in CT scan usage in children with abdominal pain were not accompanied by changes in hospital admission rates or appendicitis diagnosis rates

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Key study points:

1. Emergency department CT scan usage to assess abdominal pain has increased significantly among children aged 4 and older.

2. The increases in CT scan usage rates were not accompanied by changes in rates of hospital admission or diagnosis of appendicitis over the same period.

3. African-American children and uninsured children underwent significantly fewer CT scans.  Older children received more CT scans.

Primer: Computed tomography (CT) is becoming an increasingly popular imaging modality for the assessment of numerous ailments in emergency departments (EDs) across the world. As rates of use rise, the benefits of CT scans for different indications in pediatric patients continue to be studied with inconclusive results. Any possible benefits of this technology must be weighed against the increased long-term risk of radiation-induced malignancies; a concern that is heightened in children. In the latest issue of Pediatrics, investigators sought to demonstrate trends in CT scan usage, hospital admission and diagnosis of appendicitis in children presenting to the ED with abdominal pain over an eleven-year period.
Background reading:

1. National trends in use of computed tomography in the emergency department [Annals of Emergency Medicine]

2. Computed tomography for minor head injury: Variation and trends in major United States pediatric emergency departments [The Journal of Pediatrics]

This [cross-sectional] study: Data were collected from the 1998-2008 records of the National Hospital Ambulatory Medical Care Survey with inclusion of visits to the ED for complaints of abdominal pain among individuals under the age of 19 years old (n=5516).

Trends in hospital and patient demographics, types of imaging modalities used, disposition (admission to hospital or home), and whether a final diagnosis of appendicitis was made were determined over the eleven-year period. While rates of diagnosis of appendicitis and perforation did not change significantly (p = 0.30), there was a significant increase in CT use over the study’s time course (p < .001).  Fewer hospital admissions for children with abdominal pain were observed over this period (a 30% decrease), but the change was not statistically significant (p = 0.17). The use of other imaging modalities including MRI and radiography did not change significantly over this period either.

Predictors of CT use were decomposed using a multivariable regression model.

Older children saw the greatest increase in CT use, while the < 4 years old age group did not see significant change. Significantly fewer African-American and uninsured children received CT scans in comparison to Caucasian or insured children.

In sum: CT scan usage for assessing abdominal pain in pediatric EDs has increased markedly in the past decade.  However, hospital admission rates and diagnoses of appendicitis did not change significantly over the same period.  Although this result suggests CT scan usage did not affect these outcomes, causation cannot be inferred from a cross-sectional study such as this.  The finding of fewer hospital admissions that did not meet statistical significance raises the possibility that the study may be underpowered for detecting a real difference if it exists.

The result that African-American children and uninsured children received significantly fewer CT scans is consistent with findings of other studies cited by the authors indicating that African American children with abdominal pain in the ED often do not receive lab testing, surgical intervention, or analgesia as readily as Caucasian children.

For the outcomes measured in this study, CT scanning afforded an unclear benefit to pediatric ED patients with abdominal pain, at the cost of increased spending and radiation exposure. These results call for more robust investigations into outcomes, health disparities and cost-benefit ratios associated with CT scanning in this population.

Click to read the study in Pediatrics

Written by [LHC] and [MP]

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