Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta.
CMAJ Open. 2022 Oct 11;10(4):E889-E899. doi: 10.9778/cmajo.20210140. Print 2022 Sep-Oct.
Radiograph use contributes to low-value care for children in emergency departments (EDs), but little is known about systemic factors associated with their use. This study compares low-value radiograph use across ED settings by hospital type, pediatric volumes and physician specialty.
This is a cross-sectional study of routinely collected administrative data. We included children (age 0-18 yr) discharged from EDs in Ontario, Canada, between 2010 and 2019 with diagnoses of bronchiolitis, asthma, abdominal pain and constipation. Multiple clinical practice guidelines recommend against routine radiograph use in these conditions. Logistic regression evaluated odds of low-value radiograph by ED setting (pediatric academic [referent], adult academic, community with or without pediatric consultation services), pediatric volume and physician specialty (pediatric emergency medicine [PEM, referent], emergency medicine [EM], family medicine with EM training, pediatrics, family medicine), adjusting for demographic, clinical and provider characteristics. We used generalized estimating equations to account for clustering by ED.
Of the total 9 862 787 eligible pediatric ED discharges in Ontario, 60 914 children had bronchiolitis, 141 921 asthma, 333 332 abdominal pain and 110 514 constipation; 26.0% received low-value radiographs. Compared with pediatric EDs and PEM physicians (referents), patients with bronchiolitis were most likely to have a chest radiograph in adult academic EDs (adjusted odds ratio [OR] 5.1 [95% confidence interval (CI) 4.6-5.6]) and by family physicians with EM training (adjusted OR 4.8 [95% CI 4.5-5.1]). Patients with asthma were more likely to have a chest radiograph in adult academic EDs (adjusted OR 3.0 [95% CI 2.8-3.2]) and by EM physicians (adjusted OR 2.8 [95% CI 2.6-3.0]). Patients with abdominal pain and constipation were more likely to have abdominal radiographs in community hospitals with pediatric consultation (adjusted OR 1.6 [95% CI 1.6-1.7] and 2.3 [95% CI 2.3-2.4], respectively) and by family physicians with EM training (adjusted OR 1.6 [95% CI 1.6-1.7] and 2.1 [95% CI 2.0-2.2], respectively).
Over the decade-long study period, low-value radiograph use was frequent for children with 4 common conditions seen in Ontario EDs. Quality improvement initiatives aimed at reducing unnecessary radiographs in children should focus on EM physicians practising in EDs that primarily treat adult patients.
在急诊科（ED），X 光检查的使用导致了低价值的医疗护理，但对于与之相关的系统因素知之甚少。本研究通过医院类型、儿科容量和医生专业来比较 ED 环境中低价值 X 光检查的使用情况。
这是一项使用常规收集的行政数据进行的横断面研究。我们纳入了 2010 年至 2019 年期间在加拿大安大略省接受 ED 治疗且诊断为细支气管炎、哮喘、腹痛和便秘的 0-18 岁儿童。多项临床实践指南建议在这些情况下不常规进行 X 光检查。逻辑回归评估了 ED 环境（儿科学术[参照]、成人学术、有或无儿科咨询服务的社区）、儿科容量和医生专业（儿科急诊医学[PEM，参照]、急诊医学[EM]、具有 EM 培训的家庭医学、儿科学、家庭医学）对低价值 X 光检查的可能性，同时调整了人口统计学、临床和提供者特征。我们使用广义估计方程来解释 ED 内的聚类。
在安大略省总共 9862787 名符合条件的儿科 ED 出院患者中，有 60914 名儿童患有细支气管炎，141921 名儿童患有哮喘，333332 名儿童患有腹痛，110514 名儿童患有便秘；26.0%的患者接受了低价值的 X 光检查。与儿科 ED 和 PEM 医生（参照）相比，患有细支气管炎的患者在成人学术 ED 中最有可能接受胸部 X 光检查（调整后的优势比[OR]5.1 [95%置信区间（CI）4.6-5.6]），而接受具有 EM 培训的家庭医生的可能性更大（调整后的 OR 4.8 [95% CI 4.5-5.1]）。患有哮喘的患者在成人学术 ED 中更有可能接受胸部 X 光检查（调整后的 OR 3.0 [95% CI 2.8-3.2]）和急诊医生（调整后的 OR 2.8 [95% CI 2.6-3.0]）。患有腹痛和便秘的患者在有儿科咨询服务的社区医院更有可能接受腹部 X 光检查（调整后的 OR 1.6 [95% CI 1.6-1.7]和 2.3 [95% CI 2.3-2.4]），而接受具有 EM 培训的家庭医生的可能性更大（调整后的 OR 1.6 [95% CI 1.6-1.7]和 2.1 [95% CI 2.0-2.2]）。
在长达十年的研究期间，安大略省 ED 中常见的 4 种疾病中，儿童经常接受低价值 X 光检查。旨在减少儿童不必要 X 光检查的质量改进举措应重点关注主要治疗成人患者的 ED 中的 EM 医生。
