A recent study found African American and Hispanic children get fewer tests than Caucasian children concerning x-ray, CT, ultrasound, and MRI. This study found that when white children went to the emergency department, they were more likely to receive advanced imaging during their visit in comparison to African American or Hispanic children. This evidence points to the discrepancies in care and possible image overuse. They published their findings in the JAMA Network Open on Jan 29.
In the evidence published at this event was founded by a multi-institutional team of investigators. They found the pattern was consistent among all the exam types, regardless of what type of insurance the patient had.
“Our findings suggest that a child’s race and ethnicity may be independently associated with the decision to perform imaging during ED visits,” said the team, led by Jennifer Marin, M.D., M.Sc., associate professor of pediatrics and emergency medicine and medical director of point-of-care ultrasound at the University of Pittsburgh Medical Center Children’s Hospital. “The differential use of diagnostic imaging by race and ethnicity may reflect underuse of imaging in non-Hispanic black and Hispanic children, or alternatively, overuse in non-Hispanic white children.”
Alarmingly, the disparity can cause a variety of problems when diagnostic imaging is not equitably applied, risks surrounding radiation exposure, misdiagnoses, missed opportunities for needed follow-up care, or poorer outcomes become a concern.
To fully comprehend and obtain a clearer picture of how diagnostic imaging is used with these groups, Marin’s team evaluated data from 13,087,522 ED visits from 6,230,911 children across 44 pediatric ED nationwide. They concentrated on visits where at least one diagnostic imaging study was performed for a child under age 18 who was seen between Jan. 1, 2016, and Dec. 31, 2019. The average patient age was 5.8 years, and 52.7 percent were male.
So what stood out from this data?
According to their analysis, diagnostic imaging was performed in 3,689,163 – 28.2 percent – of ED visits. Of those encounters, 33.5 percent were for white children, 24.1 percent for African American children, and 26.1 percent for Hispanic children. And, among the types of imaging used, 79.9 percent of visits involved X-ray, 19.6 percent involved ultrasound, 10.6 percent used CT, and 2.4 percent resulted in an MRI.
Although a clear conclusion came from over and under-use based on their review of visit data, they did find that white children had a higher imaging rate for abdominal pain and trauma, as well as chest X-rays for bronchiolitis, asthma, and chest pain. The team claimed they also had higher rates of head CT even when the likelihood of head injury was low.
However, for at least half of the 26 diagnostic categories evaluated, African American and Hispanic children received less imaging, they said. African American children were only more likely to be imaged for aspects: skin and subcutaneous conditions, blood and immunological conditions, mental health, and liver and pancreatic conditions. For Hispanic children, imaging was only more likely with mental health, as well as lymphatic, hematopoietic, and other malignant conditions.
The most significant imaging volume differences between African American and Hispanic children and white children occurred with conditions related to the reproductive system, the eyes, and the digestive system, the team pointed out.
But what is the supposed cause for the disparity?
There are several potential reasons behind why these diagnostic imaging disparities exist, the team reasoned. Those factors fall into three categories: parental, clinician, and structural.
Parental factors: The investigators found that levels of parental anxiety can frequently play into whether a child receives an advanced imaging exam. Also, a language barrier can often increase or decrease the likelihood of receiving imaging orders.
Clinician factors: The implicit racial biases that a physician might have can also play into whether he or she orders an imaging test for a child. These biases can be exacerbated during times of stress, the investigators emphasized, making this a particular problem to watch in the ED setting.
Structural Factors: Minority children are less likely to have a medical home, they said, increasing the need for advanced imaging when they present to the ED. For white children, higher imaging rates could be driven by primary care provider referrals.
Ultimately, the team hopes their findings can result in work that can bring about equality among these groups for diagnostic imaging use. There is a need for measurable interventions that can lessen this problem in the ED.
“Adherence to clinical guidelines and other objective scoring tools have the potential to reduce subjectivity, support team-based decision making, and improve communication and structurally competent clinical care,” they said. “Internal quality assurance evaluations to better understand physician-level practices that may be influenced by implicit bias may also narrow the disparity gap.”