Minority Children Receive Less Advanced Imaging in the ED

White children are more likely that African American or Hispanic children to undergo some type of advanced imaging during a visit to the emergency department (ED), pointing not only to disparities in access-to-care, but also the potential for imaging overuse.

Across the board – among X-ray, CT, ultrasound, and MRI – the pattern was consistent – minority children receive fewer diagnostic imaging exams. This finding remained true regardless of what type of insurance – public or private – the patient had, said a multi-institutional team of investigators. They published their findings on Jan. 29 in JAMA Network Open.

“Our findings suggest that a child’s race and ethnicity may be independently associated with the decision to perform imaging during ED visits,” said the team led by Jennifer Marin, M.D., M.Sc., associate professor of pediatrics and emergency medicine and medical director of point-of-care ultrasound at the University of Pittsburgh Medical Center Children’s Hospital. “The differential use of diagnostic imaging by race and ethnicity may reflect underuse of imaging in non-Hispanic black and Hispanic children, or alternatively, overuse in non-Hispanic white children.”

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Either way, the team said, the disparity can create a variety of problems. When the use of diagnostic imaging is not equitably applied, risks surrounding radiation exposure, misdiagnoses, missed opportunities for needed follow-up care, or poorer outcomes become a concern.

In order to get a clearer picture of how diagnostic imaging is used with these groups, Marin’s team evaluated data from 13,087,522 ED visits from 6,230,911 children across 44 pediatric ED nationwide. They concentrated on visits where at least one diagnostic imaging study was performed for a child under age 18 who was seen between Jan. 1, 2016, and Dec. 31, 2019. The average patient age was 5.8 years, and 52.7 percent were male.

What’s Different?

According to their analysis, diagnostic imaging was performed in 3,689,163 – 28.2 percent – of ED visits. Of those encounters, 33.5 percent were for white children, 24.1 percent for African American children, and 26.1 percent for Hispanic children. And, among the types of imaging used, 79.9 percent of visits involved X-ray, 19.6 percent involved ultrasound, 10.6 percent used CT, and 2.4 percent resulted in an MRI. Just over 9 percent of visits involved more than one imaging test.

Although the team could not discern between over- and under-use based on their review of visit data, they did find that white children had a higher imaging rate for abdominal pain and trauma, as well as chest X-rays for bronchiolitis, asthma, and chest pain. They also had higher rates of head CT even when the likelihood of head injury was low, the team said.

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However, for at least half of the 26 diagnostic categories evaluated, African American and Hispanic children received less imaging, they said. African American children were only more likely to be imaged for four areas: skin and subcutaneous conditions, blood and immunological conditions, mental health, and liver and pancreatic conditions. For Hispanic children, imaging was only more likely with mental health, as well as lymphatic, hematopoietic, and other malignant conditions.

The most significant imaging volume differences between African American and Hispanic children and white children occurred with conditions related to the reproductive system, the eyes, and the digestive system, the team pointed out.

What Could Be the Cause?

There are several potential reasons behind why these diagnostic imaging disparities might exist, the team concluded. Those factors fall into three categories: parental, clinician, and structural.

Parental factors: High levels of parental anxiety can frequently play into whether a child receives an advanced imaging exam, they said. In addition, a language barrier can often increase or decrease the likelihood of receiving imaging orders.

Clinician factors: The implicit racial biases that a physician might have can also play into whether he or she orders an imaging test for a child. These biases can be exacerbated during times of stress, the team emphasized, making this a particular problem to watch in the ED setting.

Structural Factors: Minority children are less likely to have a medical home, the team said, increasing the need for advanced imaging when they present to the ED. For white children, higher imaging rates could be driven by primary care provider referrals.

Ultimately, the team said, they hope their findings can result in work that can bring about parity among these groups for diagnostic imaging use. There is a need for measurable interventions that can mitigate this problem in the ED.

“Adherence to clinical guidelines and other objective scoring tools have the potential to reduce subjectivity, support team-based decision making, and improve communication and structurally competent clinical care,” they said. “Internal quality assurance evaluations to better understand physician-level practices that may be influenced by implicit bias may also narrow the disparity gap.”

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