Parental anxiety may spur head CT overuse among white children

The odds of undergoing cranial CT among children with minor blunt head trauma who were at higher risk for clinically important traumatic brain injury did not appear to differ by race/ethnicity, according to a study published Aug. 7, in Archives of Pediatrics & Adolescent Medicine. However, “irrelevant factors” may have come into play for children at intermediate or lowest risk.

Traumatic brain injury (TBI) is a leading cause of pediatric illness and death in the U.S., responsible for 7,400 deaths, 60,000 hospital admissions and more than 600,000 emergency department visits each year. Previous studies have suggested that black children experience worse outcomes following TBI than white children.

JoAnne E. Natale, MD, PhD, of the University of California, Davis, Sacramento, and colleagues sought to better understand any disparities in evaluation and management that might be related to these outcomes. The researchers devised a secondary analysis of a prospective cohort study to determine if patient race/ethnicity is linked with CT use among children with minor blunt head trauma.

In a pediatric research network of 25 emergency departments, 39,717 children with minor blunt head trauma between June 2004 and September 2006 had their race/ethnicity documented as white non-Hispanic, black non-Hispanic or Hispanic.  

A total of 13,793 children underwent cranial CT, yielding rates of 41.8 percent, 26.9 percent and 32 percent, respectively, for white non-Hispanic, black non-Hispanic and Hispanic children, respectively. White children were consistently more likely to undergo cranial CT in the ED than the combined group of children of black non-Hispanic or Hispanic race/ethnicity, according to Natale and colleagues.

The researchers did not detect a significant difference in odds of imaging among children at higher risk for TBI. However, racial/ethnic disparities became more pronounced as risk for TBI decreased.

Children of black non-Hispanic or Hispanic race/ethnicity had lower odds of undergoing cranial CT among those who were at intermediate risk (odds ratio, 0.86) or lowest risk (odds ratio, 0.72), according to Natale et al.

They noted that parental anxiety or request influenced ordering patterns among white children, and was cited as one of the most important influences in 11.5 percent of CTs ordered in white non-Hispanic children at lowest risk for TBI, compared with 4.9 percent of CTs among black non-Hispanic or Hispanic race children at lowest risk for TBI.

“Our results suggest that physician decision making about emergency cranial CT use for minor blunt head trauma is influenced by patient or family race/ethnicity, particularly at the lowest level of injury severity, for which few children should undergo cranial CT, to avoid irradiation,” the authors wrote.

Natale and colleagues noted that disparities may compromise equity, and may arise from overuse among nonminority patients. The phenomenon “unnecessarily increases the cost of healthcare at a time when financial restraint is increasingly emphasized.” They concluded by calling for sound clinical decision making based on empirical evidence.

“Overuse is a well-recognized but largely undealt with problem in U.S. healthcare. It is perhaps nowhere more clearly demonstrated than in the use of diagnostic imaging studies,” M. Denise Dowd, MD, MPH, of Children’s Mercy Hospital, Kansas City, Mo., wrote in an accompanying editorial. “The true question should focus not on 'too much' or 'not enough' but 'is appropriate care being equally provided.'" She also identified the need for better insight into the factors that drive physician decision making.