Variation in emergency department head computed tomography use for pediatric head trauma

Objectives The objectives were to evaluate general emergency department (ED) variation in head computed tomography (CT) use for pediatric head trauma, hospital factors associated with CT use, and recent secular trends in CT utilization for pediatric head trauma. Methods This was a cross-sectional study of a sample of general EDs in the Nationwide Emergency Department Sample (NEDS; 2006–2010). The authors included visits by patients <19 years of age with International Classification of Diseases, 9th Revision, Clinical Modification, diagnosis codes for head trauma and determined head CT use via Current Procedural Terminology (CPT), Fourth Edition, codes. Crude and risk-adjusted proportions of visits with CT for each hospital were calculated using multilevel mixed effects logistic regression. The association between hospital-level characteristics and head CT were evaluated by constructing multivariable negative binomial regression models. Results There were 324,435 pediatric head trauma visits to 848 EDs in the sample. Median patient age was 8 years (interquartile range [IQR] = 2 to 15 years) and 62% of visits were by males. A minority of patients (0.7%) were severely injured, and only 4.2% were admitted to the hospital. Most EDs (79%) were nonteaching institutions, and 84% were nontrauma centers. Risk-adjusted median CT use was 56.0% (IQR = 46.4% to 64.7%). In multivariate analysis, nontrauma centers were 9% (95% confidence interval [CI] = 4% to 15%) less likely to use head CT for pediatric head trauma patients and among discharged patients, EDs within nonteaching hospitals were 8% more likely to perform CT imaging (95% CI = 2% to 14%). There was no change in CT use from 2006 through 2010 (p = 0.31). Conclusions There is significant variability among general EDs in CT use for pediatric head trauma, indicating the need for strategies to reduce variation and improve ED imaging practices for this population. Resumen Objetivos Evaluar en un servicio de urgencias (SU) la variacion en el uso de la tomografia computarizada (TC) craneal para el traumatismo craneoencefalico pediatrico, los factores hospitalarios asociados con el uso de la TC y las recientes tendencias en la utilizacion de la TC para el traumatismo craneoencefalico pediatrico. Metodologia Estudio transversal de una muestra de SU generales de la Nationwide Emergency Department Sample (NEDS; 2006–2010). Se incluyeron visitas de pacientes menores de 19 anos de edad con el diagnostico codificado de traumatismo craneoencefalico segun la Clasificacion Internacional de Enfermedades, 9° Revision, Modificacion Clinica y se determino el uso de la TC craneal segun los codigos de la Current Procedural Terminology (CPT), Fourth Edition. Las proporciones crudas y ajustadas de las visitas con TC para cada hospital se calcularon usando regresion logistica. La asociacion entre las caracteristicas del nivel de hospital y la TC craneal se evaluaron por modelos de regresion binomiales negativos multivariables. Resultados Hubo en la muestra 324.435 visitas por traumatismos craneoencefalicos pediatricos en 848 SU. La edad mediana de los pacientes fue de 8 anos (rango intercuartil [RIC] 2 a 15 anos) y un 62% fueron varones. Una minoria de los pacientes (0,7%) tuvo una lesion grave y solo un 4,2% fueron ingresados en el hospital. La mayoria de los SU (79%) fueron centros no universitarios y un 84% fueron centros no traumatologicos. La mediana de riesgo ajustado del uso de la TC fue de un 56,0% (RIC 46,4% a 64,7%). En el analisis multivariable, los centros no traumatologicos tuvieron un 9% (IC 95% = 4% a 15%) menos de probabilidad de usar la TC craneal para los pacientes con traumatismo craneoencefalico pediatrico y, entre los pacientes dados de alta, los SU de hospitales no universitarios tuvieron un 8% mas de probabilidad de realizar una TC (IC 95%= 2% a 14%). No hubo cambio en el uso de la TC desde 2006 hasta 2010 (p = 0,31). Conclusiones Hay una variabilidad significativa entre los SU generales en el uso de la TC para el traumatismo craneoencefalico pediatrico, lo cual indica la necesidad de estrategias para reducir la variacion y mejorar las practicas de imagen en el SU para esta poblacion.