The use of CT scans remained constant — and even declined — in two major Atlanta pediatric emergency departments during a time when CT use was generally on the rise. A retrospective review between 2003 and 2010 of nearly one million electronic records found rates of CT use decreased where alternative non-radiation modalities were options. (Pediatrics 2012;129:e690.)
The researchers, led by pediatric emergency physician Margaret Menoch, MD, who now divides her time between Children's Healthcare of Atlanta and a Michigan hospital, found that CT scans were performed in 5.5 percent of the 987,932 eligible pediatric emergency visits. The lion's share of these (63%) were head CTs, while 20 percent were of the abdomen and pelvis, three percent wer of the cervical spine, and 14 percent were classified as “other.”
High-acuity complaints for head injury and seizure increased during the study period, but CT use declined significantly for those chief complaints: seizure (β-0.974; 95% CI [-1.44 to -0.90]) and head injury (β-0.93; 95% CI [-1.71 to -0.73]).
The study, although limited to one health system, suggested that efforts to minimize CT use in pediatric patients is having some success. That is an important finding given the growing body of evidence about the risks of excessive CT scan use. “This article very well addresses the concerns that have developed over the last decade about the alarmingly high rate of CT use in children,” said Michael Kim, MD, the chief of pediatric emergency medicine at the University of Wisconsin School of Medicine and Public Health. “It indicates that we can, as pediatric emergency physicians, change the course of history. It's a trend I hope we will see in more academic medical centers, and ultimately in community emergency departments where the majority of children are cared for.”
The risks of CT overuse in children were underscored again in June with a new paper in The Lancet by David Brenner, MD, the director of the Center for Radiological Research at the Columbia University College of Physicians and Surgeons and a well known expert on radiation risk who helped develop the ALARA (As Low As Reasonably Achievable) standards to keep exposures to ionizing radiation as far below the dose limits as practical.
Using records from nearly 180,000 children who had CT scans in Great Britain between 1985 and 2002, Dr. Brenner and his colleagues found a dose-response relationship: the more scans the children had and the more radiation they received, the higher their risk of subsequent cancers. Children under 15 who had two or three head CTs had a threefold increased risk of brain cancer; those receiving five to 10 scans had a threefold increased risk of leukemia.
“With new technologies like ultrasound and quick brain MRI becoming more available in pediatric emergency departments, we're going to other imaging modalities first and using CT only when the other imaging is inconclusive,” said Allen Hsiao, MD, an associate professor of pediatrics and emergency medicine and the chief information officer at Yale-New Haven Hospital. “At our institution two or three years ago, I could have counted on one hand the number of MRIs we'd do over the course of several months in the pediatric ED, but now it's not that unusual to do two or three a day. Especially in patients with indications such as seizure, we are using MRIs a lot more.”
Ultrasound is becoming the imaging modality of choice for abdominal complaints in children. In fact, 2013 was declared the “Year of Ultrasound First” by the American Institute of Ultrasound in Medicine, which hopes to call attention to its advantages as a first-line imaging option over radiation-emitting modalities such as CT. “It's quickly become standard of care in most pediatric hospitals to use ultrasound first to diagnose appendicitis,” said David Kessler, MD, MSc, the director of clinical operations for pediatric emergency medicine at Columbia University Medical Center in New York, who pursued specialty training in diagnostic ultrasonography so he could better take advantage of the modality.
“Here at the New York Presbyterian/Morgan Stanley Children's Hospital, we even go a step further,” Dr. Kessler said. “If the ultrasound is not definitive, we will actually do an MRI for suspected appendicitis before going to CT. We make every effort to only do CT scans when absolutely necessary.”
Of course, pediatric emergency departments at institutions like Children's in Atlanta and Columbia may be more focused on the risks of CT to children than community-based, non-specialty EDs where more than 80 percent of children still receive emergency care, Dr. Menoch said.
Dr. Hsiao said physicians recognize the increased risk from CT radiation, but it is not as high on the radar in general emergency departments as it is in pediatrics. “Based on patients transferred to us, we definitely see that the use of CT elsewhere in the community is very variable,” he said. “There are some EDs where they still jump right to a CT scan instead of ultrasound in a preschooler with an abdominal complaint, or a head CT after an injury where observation might have been more appropriate.”
Ultimately, some of today's emergency medicine residents who rotate through pediatric emergency departments will become tomorrow's attendings in community EDs, so a change in practice will come, but are there ways to make it happen faster? One possibility may lie with the growing use of electronic medical records and computer-assisted decision tools.
“This is a perfect scenario for clinical decision support,” Dr. Hsiao said. “As the physician — no matter what the setting — orders a CT scan, perhaps logic can be written in so that the system will inquire about things such as the indication and age of the patient, and an algorithm [could] generate prompts suggesting alternative imaging modalities along with links to the evidence.”
The Image Gently campaign, launched in 2007 by the Alliance for Radiation Safety in Pediatric Imaging, also promotes judicious use of imaging in children. The joint effort of the American College of Radiology, the Society for Pediatric Radiology, the American Association of Physicists in Medicine, and the Society of Radiation Technologists also teaches providers how to “child-size” radiation doses and shield vulnerable organs from radiation.
The Food and Drug Administration also proposed new guidelines over the summer that would call on manufacturers of new imaging devices to provide information on how to minimize radiation exposure for children based on their ages and sizes and to label scanners as “not for pediatric use.”
Dr. Menoch stressed that her group's research is not meant to condemn CTs. “CTs are a valuable and accurate diagnostic tool,” she said. “We're not trying to tell people not to use them. We're just depicting what's going on and making people aware that there are alternative ways to evaluate common chief complaints, especially in children.”
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