Overuse of the Emergency Department and CT Scans in Pediatric IBD: Time for Hot Spotting? 

Jennifer L. Dotson and yMichael D. Kappelman

See ‘‘Emergency Department Visits Related to Inflammatory Bowel Disease: Results From Nationwide Emergency Department Sample’’ by Pant et al on page 282.


s pediatric providers, are we optimally managing our patients with inflammatory bowel disease (IBD)? Are we providing timely, effective care to maintain remission and prevent diseaseand/or treatment-related complications? The article published by Pant et al in this issue of the Journal of Pediatric Gastroenterology, and Nutrition reports evidence suggesting we may not be (1). The authors analyzed data from a large national US database of emergency department (ED) encounters (Healthcare Cost and Utilization Project Nationwide Emergency Department Sample [HCUPNEDS]) to evaluate time trends in ED use and subsequent hospital admission; describe the use of radiology, endoscopic, and surgical procedures; and identify factors associated with hospital admissions. The main finding was an increasing trend in the number of ED visits for IBD between 2006 and 2010. At one level, this trend may be explained by an increased disease burden either because of a rising prevalence of IBD, or perhaps higher morbidity or disease severity leading to ED visits (2,3). The majority of the visits did not result in a hospitalization, surgery, or other emergency procedure, however, which suggests they were unlikely to be true emergencies and probably could have been managed on an outpatient basis. Indeed, Hoffenberg et al (4) recently published a multicenter retrospective review of consecutive ED encounters for pediatric patients with IBD and found that half of the ED visits could have been avoided in a more optimal health care system. Another important finding was the alarming increase in computerized tomography (CT) use (80% for Crohn disease [CD] and 59% for ulcerative colitis [UC]) over time, which is particularly concerning given the risk of radiation exposure. We find this perplexing because ultrasound and magnetic resonance imaging (MRI) are becoming more commonplace, and providers are increasingly aware of the cumulative effects of radiation exposure in children with IBD (5,6). Radiologic studies are

Received April 27, 2015; accepted May 12, 2015. From the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Center for Innovation in Pediatric Practice, Nationwide Children’s Hospital, Columbus, OH, and the yDepartment of Pediatrics, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC. Address correspondence and reprint requests to Michael D. Kappelman, MD, MPH, Department of Pediatrics, Division of Gastroenterology and Hepatology, University of North Carolina, 247 MacNider Hall, CB No. 7229, Chapel Hill, NC 27599 (e-mail: [email protected] The authors report no conflicts of interest. Copyright # 2015 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0000000000000866


Volume 61, Number 3, September 2015

important in the diagnosis of IBD and the evaluation of complications (eg, abscess, stricture, fistula, and bowel obstruction) (5,7–10). The availability of CT, stability of the patient, and practitioner preference (including defensive medicine) are likely factors that contribute to the use of CT in the ED setting. Other studies have also highlighted the high use of CT among children with CD (5,6,11). Palmer et al (12) found that in a 2-year period, approximately one-third of patients with CD and one-fourth of patients with UC were exposed to moderate diagnostic radiation. For both CD and UC, moderate radiation exposure was associated with hospitalization, surgery, and ED encounters. As physicians, we must be mindful of the radiation risks of diagnostic imaging in children and adolescents with IBD by being proactive and thoughtful when ordering testing. Is imaging really necessary? Is this CT going to change the management of this patient? If imaging is needed, could ultrasound or MRI be used in place of CT? This article also provides an excellent opportunity to further explore the limitations common to all studies based upon administrative data. Readers must keep in mind that these data, including International Classification of Diseases, 9th Revision (ICD-9) codes, are collected for billing purposes rather than research (or clinical care). In many cases, neither the completeness nor the accuracy of diagnosis codes has been validated. Thus, there is potential for misclassification of IBD (eg, some cases may be missed and other incorrectly coded as having IBD). Furthermore, symptom-based diagnosis codes may have even less fidelity. For example, in the present study, the primary symptoms of UC, lower gastrointestinal bleeding and diarrhea, were recorded by ICD-9 codes in only 12.4% and 5.3% of the visits, respectively. Similarly, the most common symptom in CD was abdominal pain, which was recorded

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