Pediatric inpatients more likely to undergo higher rad dose exams

Children are undergoing more frequent and higher radiation diagnostic imaging procedures, according to a study published online Dec. 3 in Pediatrics. Higher radiation dose procedures were most frequently performed in the inpatient and emergency settings, leading the researchers to suggest that interventions to reduce radiation exposure target both emergency and inpatient practices.

Image Gently has not been fully implemented in adult settings that serve children, according to Trevor Tompane, MPH, from the department of pediatrics at University of California, San Diego, and colleagues. “Similarly, much work remains to be done in regards to changing how clinicians order diagnostic imaging procedures to reduce ionizing radiation exposure to ‘as low as reasonably achievable,’” wrote Tompane et al.

Thus, the researchers sought to determine the prevalence and characteristics of diagnostic imaging procedures among a general pediatric population. They collected claims data from an independent physicians’ association linked with a tertiary care hospital from Jan. 1, 2001, through Dec. 31, 2009.

A total of 214,538 procedures were performed on 63,116 unique children. Tompane and colleagues estimated that one in three children underwent imaging during the study period. The most common exams were radiography, ultrasound and CT.

Sixty percent of the population underwent two or fewer exams during the study period. Sixty-two percent of the children who underwent higher radiation exams (CT, angiography or fluoroscopy) underwent only one higher radiation dose exam.

Trend analysis showed significant increases in frequency of CT, MRI and ultrasound in proportion to the increasing population of insured patients. The likelihood of CT increased by 34 percent over the study period, and the likelihood of MRI increased by 84 percent.

The performance of higher radiation dose exams was higher in the inpatient and emergency department settings, among patients with gastrointestinal and congenital anomaly ICD-9 codes and among older (ages 13 and older and five to 12 years) versus younger (one to four years and younger than one year) patients.

“[Although] the literature confirms our findings that the ED should be a primary area of focus for reduction of performance of higher radiation diagnostic imaging procedures, our data suggest that the greatest risk for higher radiation diagnostic imaging procedure performance occurs in the inpatient setting,” wrote Tompane et al.

The researchers also observed performance of CT, angiography and fluoroscopy for ICD-9 codes for which these exams are not routinely indicated, such as abdominal pain and headaches/head injuries. In contrast, they noted that clinical studies have reported benefits to such procedures, and the American College of Radiology Appropriateness Criteria term higher radiation exams as “usually” appropriate in the setting of abdominal pain and fever and certain categories of headache patients.

Clinical practices diverge from these guidelines, according to Tompane and colleagues, who called for improved conversations between professional societies authoring guidelines and clinicians performing care to ensure appropriate and adequate use of imaging exams.