Many readers here are students, trainees, or otherwise academic-affiliated, and have limited exposure to the world of community practice. In these settings, frequently, our pediatric exposure is supervised by clinician-educator sub-specialists in Pediatric Emergency Medicine. We see the very best evidence translated into acute care of children in the Emergency Department.
The real world is a little different.
These two articles describe the shortcomings of advanced imaging practice in community pediatric settings – in the diagnosis of appendicitis, and in the evaluation of closed head injury.
In the appendicitis article, the authors compare two settings both staffed by PEM physicians – an academic medical center with in-house pediatric surgical coverage, and a community center with consultation available only by phone. Each site had similar rates of appendicitis diagnoses – 4.7% vs. 4.0% at the academic and community site, respectively. The academic site, however, evaluated fewer patients with abdominal pain with blood work, and then fewer still of those went on to advanced imaging. Then, of those receiving advanced imaging, the rates were 10.8% CT at the academic center vs. 28.1% CT at the community center. Ultrasound however, was employed in 16.6% of cases at the academic center versus 6.5% at the community practice. Nearly all this difference, however, seemed to be made up of patients admitted to the hospital without any operative intervention. The obvious reality, then: radiation in lieu of observation.
The second article here describes the neuroimaging (CT or MRI) of patients evaluated following trauma, along with their ultimate disposition. Of 2,679 patients reviewed, there were 94 patients with important non-surgical, trauma-related diagnoses, and an additional 16 patients who required neurosurgical intervention. These authors, however, based on GCS estimates recorded and the distribution of outcomes in the PECARN study, estimate the prevalence of entry criteria into appropriate scanning would have obviated >2000 of these scans. While I believe they are probably mis-applying the evidence and overstating the inappropriateness of CT, the rarity of serious diagnoses suggests at least a majority of these CTs probably could have been avoided.
In short, we’re still doing too many CTs on children. Some of the contributing issues are systems based, and some are related to practice re-education. More ultrasound and more observation, please – and less nuking of children.
“Imaging for Suspected Appendicitis: Variation Between Academic and Private Practice Models”
“Neuroimaging Rates for Closed Head Trauma in a Community Hospital”