The Rising Use of X-Ray for Pediatric Asthma in the ED

X-ray use for diagnosing pediatric asthma in the emergency department increased over the last few decades, despite hopes that more selective use would reduce radiation and cost.

A significantly increased number of radiographs were ordered for pediatric asthma from 1995 to 2009, according to a retrospective study published recently in Pediatrics. Although researchers found a yearly odds ratio of 1.06 for the increased use of radiographs for asthma, compounded over time this results in a “much greater 2.4-fold increase in the odds of utilizing radiographs,” they wrote.

Research chose to examine asthma, bronchiolitis and croup, because they are common respiratory illnesses in children and are common reasons for emergency department visits in childhood, according to study investigator Jane F. Knapp, MD, of Children’s Mercy Hospitals and Clinics.

"These illnesses also have defined performance indicators and either published guidelines or strong research regarding care,” Knapp said. “We thought it was important to study because there are many good reasons to limit the use of X-rays in children especially in an illness as common as asthma.”

Among those reasons are a reduction in healthcare costs, radiation exposure and an improvement in emergency department efficiency by shortening the length of stay.

Knapp and colleagues looked at data from 1995 to 2009 from the National Hospital Ambulatory Medical Care Survey on radiograph use in emergency departments for children. Data was included for visits for children with asthma aged 2  to 18, children with bronchiolitis aged 3 months to 1 year, and children with croup aged 3 months to 6 years.

During the study, there were 6.3 million visits for asthma, 2.8 million visits for bronchiolitis, and 4.2 million for croup. There was an upward trend for the use of radiograph when diagnosing moderate to severe asthma during this time (OR=1.6; 95% CI, 1.03-1.09; P<.001). According to Knapp, researchers were hoping to have found a decreasing trend in the use of X-ray during this time.

In contrast, no similar trend for radiographs for bronchiolitis or croup was seen.

“Although we did not mention this in the article, the lack of a decrease in X-ray use for bronchiolitis and croup is also disappointing,” Knapp told Diagnostic Imaging. “We would have hoped that by applying the results of research in bronchiolitis and croup, X-ray usage would have decreased.”

The researchers did find statistically significant decreased use of radiographs for all three of the conditions among pediatric-focused emergency departments. When the data were isolated by region, the researchers found that radiograph use was increased for all three conditions in the Midwest and the South compared with the Northeast, and the West had increased use of radiographs for asthma alone.

“We need to develop more precise guidelines for the emergency department clinician to apply for the use of X-rays especially in children with asthma,” Knapp said. “Then individuals, hospitals and systems need to be held accountable for their performance.”

Knapp said that physicians should not to order X-rays as a routine part of the emergency department care for children with asthma, bronchiolitis and croup. 

“Think about the indications,” she said, “and do your best to avoid the radiation exposure and cost.”