Variation in the Use of Chest Radiography for Pneumonia in Pediatric Emergency Departments

Abstract

We sought to examine the utilization of chest radiography among children with pneumonia and other respiratory illnesses and to investigate interinstitution chest radiograph (CXR) utilization to identify if there is a relationship between CXR utilization and rate of pneumonia. This is a retrospective study of children evaluated in an emergency department at 25 institutions contributing information to the Pediatric Health Information System database from 2003 to 2008. The use of chest radiographs was determined for patients with a diagnosis of pneumonia, upper respiratory tract illness, wheeze, and fever. Over a 6-year period, pneumonia accounted for 2.1% of all visits to an emergency department. Comparing institutions, the proportion of children with a diagnosis of pneumonia who had a CXR obtained ranged from 38% to 88%. There was no observed association between CXR utilization rate and the proportion of patients with a diagnosis of pneumonia between institutions. There was also a wide variation in the use of CXR for other diagnoses (upper respiratory tract infection [range, 9%-36%], wheeze [14%-56%], fever [7%-41%]). Eighty-percent of children hospitalized with pneumonia had a radiograph obtained, compared with 76% of children with pneumonia discharged from the ED (P = 0.28). However, the rate of utilization of CXR for patients hospitalized with other diagnoses was higher than respective rates of CXR use for discharged patients (upper respiratory tract infection, 68% vs 16% [P < 0.001]; wheeze, 57% vs 23% [P < 0.001]; and fever, 45% vs 18% [P < 0.001]). The use of CXR varies widely among pediatric emergency departments but does not appear to influence the institution-specific rate of pneumonia.