Background: Chest x-rays (CXR) are overused in children visiting emergency departments (EDs) with asthma, bronchiolitis, and croup. Despite guidelines recommending limited use, little is known about drivers of imaging overuse. Within a multi-institutional quality initiative, we analyzed the Michigan Emergency Department Improvement Collaborative (MEDIC) clinical registry to identify factors associated with CXR use.
Methods: Children visiting any of 11 MEDIC hospital EDs, 3 pediatric (PED) 8 general (GED), between 4/1/2017-3/31/2018 with ICD10CM diagnosis codes for asthma (ages 2-17 years), bronchiolitis (ages 0-2 years), and croup (ages 6 months-3 years) were included. CPT codes determined CXR use. Electronic medical record data was supplemented with clinical information from chart abstraction by trained personnel. Odds ratios with 95% confidence intervals (CI) were calculated from generalized estimating equations models adjusted for patient demographics, ED visit information, and clinical factors a priori hypothesized to influence CXR use by diagnosis. Separate models were generated to compare differences between GEDs vs PEDs.
Results: CXR was used in 2618/7725 (33.9%) of ED visits for asthma, 2209/4380 (50.4%) for bronchiolitis, and 406/2303 (17.6%) croup. Overall CXR use was higher in GEDs than PEDs (44% vs. 33%). Triage acuity, hospitalization, concern for foreign body aspiration and presence of tracheostomy conferred highest odds for CXR use for all conditions. Other clinical factors with higher odds for CXR in asthma: temp >38C (OR 2.03, CI 1.74-2.37), fever within 24 hrs. (OR 1.83, CI 1.44-2.34), pulse ox < 90% (OR 1.69, CI 1.40-2.03). Bronchiolitis: temp >38C (OR 1.53, CI 1.31-1.79), pulse ox < 90% (OR 1.51, CI 0.90-2.51), wheezing in ED (OR 1.28, CI 1.05-1.56). Croup: wheezing in ED (OR 2.01, CI 1.36-2.97), fever within 24 hrs. (OR 1.26, CI 1.06-1.51). Key differences between GED vs PED in factors associated with CXR use: asthma, wheezing in ED (OR 1.51, CI 1.16-1.96); bronchiolitis, pulse ox < 90% (OR 2.02, CI 1.12-3.66) and wheezing in ED (OR 1.69, CI 1.36-2.09); croup, fever within 24 hrs. (OR 1.35, CI 1.02-1.80).
Conclusion: CXR use in children with asthma, bronchiolitis and croup was common across MEDIC’s diverse group of EDs. Differences in the odds of CXR use between GED and PEDs tied to clinical features suggest potential targets for QI interventions to safely reduce overtesting in both settings.