Regional and socioeconomic disparities in emergency department use of radiographic imaging for acute pediatric sinusitis Ahmad R. Sedaghat, M.D., Ph.D.,1,2 Michael J. Cunningham, M.D.,2,3 and Stacey L. Ishman, M.D., M.P.H.4,5
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ABSTRACT
Background: Acute pediatric sinusitis (APS) is a common complication of pediatric upper respiratory tract infections. Children with all degrees of APS severity may present to emergency departments (EDs) for evaluation and management. This study was designed to analyze the use of imaging in APS presenting to U.S. EDs. Methods: A cross-sectional analysis of the 2008 National Emergency Department Sample database was performed. One hundred one thousand six hundred sixty children, aged ⱕ18 years, assigned at least one ICD9 code for APS were identified. Current procedural terminology codes for sinus plain film radiographs, computed tomography (CT), and magnetic resonance imaging identified children who underwent sinus imaging. Association of performance of sinus imaging was sought with multiple predictor variables including clinicodemographic and hospital characteristics. Results: The use of any imaging was associated with older age (odds ratio [OR] ⫽ 1.07; p ⬍ 0.001), male gender (OR ⫽ 1.57; p ⬍ 0.001), and diagnosis of chronic rhinosinusitis (OR ⫽ 2.46; p ⬍ 0.001). Imaging was more common in metropolitan teaching (OR ⫽ 1.40;0 p ⬍ 0.001) and nonteaching (OR ⫽ 5.64; p ⬍ 0.001) hospitals. Markers of higher socioeconomic status—private health insurance (OR ⫽ 1.37; p ⬍ 0.001) and higher income level (OR ⫽ 1.96; p ⬍ 0.001)—were associated with greater use of imaging, especially CT scans. Conclusion: The use of ED imaging in APS is appropriately associated with factors known to be associated with APS complications. However, additional disparities with respect to regional and socioeconomic factors exist. Interventions to eliminate these health care disparities in use of imaging resources may lead to quality improvement in care and outcomes for APS. (Am J Rhinol Allergy 28, 23–28, 2014; doi: 10.2500/ajra.2014.28.3992)
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cute pediatric sinusitis (APS) is a common occurrence in the pediatric population, arising frequently as a complication of upper respiratory tract infection1,2 and accounting for approximately one million ambulatory visits annually.3 The diagnosis of APS is largely based on clinical grounds as per guidelines established by the American Academy of Pediatrics.4–6 Imaging is generally not recommended for the routine diagnosis of APS in children. This recommendation is based on the high positive predictive value of the clinical history and the nonspecificity of radiographic findings. The quality and interpretation of plain film radiography depends on both the cooperativeness of the child and the experience of the operator, either of which may predispose to an under- or overestimation of sinusitis.7 Even more advanced imaging such as computed tomography (CT) can be nonspecific. Paranasal sinus opacification and mucosal thickening are common incidental findings on review of sinus CT scans in children and adolescents.8,9 Approximately 50% of children may have sinus opacification on CT scan regardless of upper respiratory tract symptoms.9 The use of advanced imaging such as CT or magnetic resonance imaging (MRI) in the diagnostic workup of APS is therefore typically reserved for recurrent or chronic cases or in situations in which there is concern for orbital or intracranial complications.4,5,10 Children with both uncomplicated and complicated APS commonly present to emergency departments (EDs).3,11 Therefore, ED physicians are often faced with the task of determining which of these
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From the 1Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, 2Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, 3Department of Otolaryngology and Communication Enhancement, Children’s Hospital Boston, Boston, Massachusetts, and Divisions of 4Otolaryngology–Head and Neck Surgery and 5Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio The authors have no conflicts of interest to declare pertaining to this article Address correspondence to Ahmad R. Sedaghat, M.D., Ph.D., Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114 E-mail address: [email protected] Copyright © 2014, OceanSide Publications, Inc., U.S.A.
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children would benefit from imaging. In this study, the use of imaging in the diagnosis of APS in children is studied through a crosssectional analysis of a comprehensive national database of ED visits. Previous studies have shown that lower socioeconomic status may be associated with a disparate quality of health care for children,12 including in the ED setting.13 Hospital-specific factors such as geographic location and academic affiliation can be associated with disparate health care costs as well.14,15 By characterizing patient-specific and hospital-specific factors associated with the use of imaging in the diagnostic workup of APS, substantial disparities in health care use and costs may be identified and ideally minimized.
MATERIALS AND METHODS Screening for Study Subjects The 2008 National Emergency Department Sample (NEDS) database, a comprehensive and representative nationwide database of patient and hospital characteristics associated with ED visits in the United States, was screened for APS by searching for all patients ⬍18 years of age with at least one ICD9 code for acute sinusitis (461.0, 461.1, 461.2, 461.3, 461.8, and 461.9) assigned to any of the first five diagnoses. A total of 101,660 pediatric patients were found. Children were further screened for the use of imaging by searching for a concomitant current procedural terminology code for sinus plain film (70210 or 70220), sinus CT scan (70480, 70481, 70482, 70486, 70487, or 70488), or sinus MRI (70540 or 70543). Patient demographic characteristics of age and gender were extracted, as were insurance types and median income levels by zip code (referred to as estimated median household income level in the text and as previously described in the Uninsured Hospital Stays report),16 the latter serving as proxy measures for socioeconomic status. Insurance type was categorized16 as (1) Medicaid, which includes both fee-for-service and managed care Medicaid plans; (2) private, which includes Blue Cross and commercial carriers, as well as private Health Maintenance Organizations and Preferred Pro-
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23
vider Organizations; (3) uninsured patients where “self-pay” was listed as the primary payer; (4) no charge, which consists of patients for whose ED visit the hospital did not charge the patient or insurer; and (5) other, which includes other governmental programs such as TRICARE/CHAMPUS, CHAMPVA and Title V. For each patient, total ED costs were tabulated in and directly obtained from the NEDS database. Comorbidities such as chronic rhinosinusitis (CRS; ICD9 code 473.0, 473.1, 473.2, 473.3, 473.8, or 473.9) were considered, as were human immunodeficiency virus (HIV) infection (Clinical Classifications Software [CCS] code 5), lymphoma (CCS codes 37 or 38), leukemia (CCS code 39), cystic fibrosis (CCS code 56), and immune disorders (CCS code 57, associated with all ICD9 codes for “disorders involving the immune mechanism,” such as deficiencies of humoral immunity, deficiencies of cellular immunity, or combined immune deficiency). These comorbid diagnoses were considered to be caused by their impact on the immune system and concern that they may accelerate the clinical course of APS, influencing emergency physicians to obtain additional imaging. Complications of APS were identified by screening for the following ICD9 codes: preseptal periorbital cellulitis (373.13), orbital complications including orbital cellulitis and abscess (376.0, 376.01, 376.02, and 376.03), and intracranial complications including intracranial epidural and subdural abscesses (324.0) and cavernous sinus thrombosis (325.0). Hospital characteristics including U.S. region and teaching status were extracted directly from the NEDS. Regions were categorized as northeast, south, midwest, and west, and teaching status was categorized as nonmetropolitan, metropolitan teaching, and metropolitan nonteaching, each as previously defined in the NEDS.16
age of these patients was 8.6 years (SD, 5.7 years) with a gender composition of 50.1% male and 49.9% female patients. Sinus plain film radiographs were performed on 852 children (0.8%), and 1607 patients underwent a sinus CT scan (1.6%). No children were recorded as having undergone MRI of the sinuses. Although the average charge associated with children with APS who did not undergo any imaging was $751, the average ED charges associated with children who underwent plain film radiography and CT scan were $1563 and $3534, respectively. Diagnoses of CRS or other comorbidities such as HIV infection, lymphoma, leukemia, cystic fibrosis, or immune disorders were made in ⬍1% of patients (Table 1). APS complications were diagnosed in 696 (0.7%) patients. Medicaid (50%) and private insurance (35.9%) were the most common primary insurance types listed. Both patient-specific and hospital-specific characteristics of children with APS who either did or did not undergo sinus imaging (Table 1) were noted and further explored for statistically significant association.
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Strategies to Reduce Confounding Effects Statistical analyses were additionally performed using only patients who had acute sinusitis ICD9 codes as the primary (first) diagnosis code or as 1 of all 15 diagnosis codes with no qualitative change to the reported results (calculated for patients with an acute sinusitis ICD9 as 1 of the first 5 diagnosis codes). Similarly, analyses were performed including nonspecific imaging protocols: CT head (70450, 70460, and 70470), x ray of the skull (70250 and 70260), x ray of the orbits (70200), and x ray of the facial bones (70140 and 70150). In all cases, these different analyses produced qualitatively similar results as those presented later in text. Additionally, patient comorbidities and concurrent diagnosis of APS complications (e.g., preseptal cellulitis, orbital, and intracranial abscesses) were included in all multivariate analyses to account for patient illness and APS severity in the usage of imaging.
RESULTS Characteristics of Study Subjects Overall, 101,660 pediatric patients were diagnosed with APS in EDs nationwide, with average ED charges of $804 per patient. The average
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Characteristics associated with ED imaging of the paranasal sinuses by plain film radiography or CT scan were evaluated. Patient-specific characteristics noted to be statistically associated with the use of imaging included older age (OR ⫽ 1.07; p ⬍ 0.001) and male gender (OR ⫽ 1.57; p ⬍ 0.001). The diagnosis of CRS was also associated with an increased use of imaging (OR ⫽ 2.20; p ⬍ 0.001), whereas comorbidities such as HIV infection, lymphoma, leukemia, cystic fibrosis, or immune system disorders were not. As would be expected, complications of APS were also associated with the use of imaging (OR ⫽ 2.25; p ⬍ 0.001). Children from higher-income groups tended to receive imaging studies more often, with the greatest difference between those children from the highest and lowest income groups (OR ⫽ 1.98; p ⬍ 0.001). Moreover, patients with Medicaid and those who were uninsured were least likely to receive imaging. Patients with private insurance (OR ⫽ 1.38; p ⬍ 0.001), those who were not billed by the hospital (designated “no chargef”) for their visit (OR ⫽ 5.62; p ⬍ 0.001), and other types of insurance (e.g., TRICARE/CHAMPUS, CHAMPVA, Title V and other government programs; OR ⫽ 1.49; p ⬍ 0.001) were all more likely to receive imaging than those patients who had Medicaid. Some diversity in the use of ED imaging was associated with hospital characteristics. Patients presenting to metropolitan teaching hospitals (OR ⫽ 1.39; p ⬍ 0.001) and, to a greater extent, metropolitan nonteaching hospitals (OR ⫽ 2.22; p ⬍ 0.001) were more likely to receive imaging compared with those presenting to EDs in nonmetropolitan areas. Regionally, midwestern EDs were least likely to use imaging in the workup of APS compared with EDs in the west (OR ⫽ 2.88; p ⬍ 0.001), south (OR ⫽ 4.45; p ⬍ 0.001), and northeast (OR ⫽ 6.92; p ⬍ 0.001). Subgroup analysis was performed to further evaluate associations between patient- and hospital-specific factors with the use of sinus plain film radiographs (Table 2 and Fig. 1) or CT (Table 3 and Fig. 2). Older children were more likely to undergo sinus plain film radiography (OR ⫽ 1.03; p ⬍ 0.001; Fig. 1 A) and CT scans (OR ⫽ 1.08; p ⬍ 0.001; Fig. 2 A). Boys were also more likely to undergo sinus plain film radiography (OR ⫽ 1.16; p ⫽ 0.032) and CT scan imaging (OR ⫽ 1.82; p ⬍ 0.001). Comorbid conditions such as HIV infection, lymphoma, leukemia, cystic fibrosis, or immune system disorders were not associated with the use of sinus plain films or CT scan imaging. Although also not associated with sinus plain films, a concomitant diagnosis of CRS (OR ⫽ 3.05; p ⬍ 0.001) or a complication of APS (OR ⫽ 3.03; p ⬍ 0.001) was associated with the use of CT scan imaging. Similar to the use of imaging in general, children from the highest estimated median household income level were more likely to undergo a sinus plain film (OR ⫽ 1.77; p ⬍ 0.001; Fig. 1 A) or CT (OR ⫽
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Statistical Analysis All analyses were performed with the statistical software R (www.r-project.org). Associations between the ascertainment of imaging and predictor variables were determined with the logistic regression function lrm() in the rms package.17 Univariate logistic regression was performed for each predictor variable. Multivariate logistical analysis was performed using all predictor variables. In the multivariate model, significant predictors were identified via backward elimination, using a p-value cutoff of 0.100. Cross-validation was performed through bootstrapping of the data set using the validate function from the rms package over 100 iterations. For each variable retained in the final model, a p-value and a log-odds ratio (OR) were calculated.
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Patient and Hospital Characteristics Associated with Radiographic Imaging
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Table 1 Clinicodemographic factors of pediatric patients diagnosed with APS in the ED All
Sinus Plain Film No
Patient characteristics Number of patients Fraction of patients (%) Age (yr) Gender (% male) CRS (%) Other comorbidities* (%) Median income# Primary payer (%) Medicaid Private Uninsured No charge Other ED charges ($) Hospital characteristics Region (%) South Northeast Midwest West Teaching status (%) Nonmetropolitan Metropolitan teaching Metropolitan nonteaching
101,660 100 8.6 50.1 0.3 0.2 2.0
100,808 99.2 8.6 50.1 0.3 0.2 2.0
50.2 36.0 9.7 0.1 4.0 804.41
50.3 36.0 9.7 0.1 4.0 797.59
49.9 12.2 30.3 7.6
49.8 12.1 30.4 7.7
34.2 40.8 25.0
T 34.2 40.9 24.9
CT Scan Yes
852 0.8 9.6 52.7 0.5 0.0 2.2
No 100,053 98.4 8.5 49.9 0.3 0.2 2.0
Yes 1607 1.6 10.9 62.6 1.6 0.3 2.5
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41.9 40.5 12.2 0.4 5.3 1563.25
50.4 35.7 9.8 0.1 4.0 758.35
35.9 53.2 6.8 0.8 4.2 3534.14
61.8 24.0 9.9 4.3
50.0 11.8 30.6 7.6
45.6 36.8 8.4 9.2
27.7 28.5 43.8
34.5 40.8 24.7
15.2 43.5 41.3
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*Other comorbidities: HIV infection, lymphomas, leukemias, cystic fibrosis, and/or immune disorders. #Quartile classification (with respect to the entire United States) of the estimated median household income of residents in the patient’s zip code. HIV ⫽ human immunodeficiency virus; APS ⫽ acute pediatric sinusitis; ED ⫽ emergency department; CRS ⫽ chronic rhinosinusitis.
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2.03; p ⬍ 0.001; Fig. 2 A) than children from the lowest household income level. Children with Medicaid or no insurance at all were least likely to undergo either type of imaging, and children with private health insurance were more likely to receive either a sinus plain film radiograph (OR ⫽ 1.23; p ⫽ 0.012) or CT scan (OR ⫽ 1.43; p ⬍ 0.001). Similarly, children on other governmental insurance programs were more likely to receive a sinus plain film radiograph (OR ⫽ 1.49; p ⫽ 0.019) or CT scan (OR ⫽ 1.46; p ⬍ 0.001). Compared with children with Medicaid, children who were uninsured were more likely to receive a sinus plain film (OR ⫽ 1.30; p ⫽ 0.022) but less likely to receive a sinus CT scan (OR ⫽ 0.72; p ⫽ 0.003). Hospital characteristics were also associated with the use of sinus plain films (Fig. 1 B) or CT scans (Fig. 2 B) for children with APS. EDs located in nonmetropolitan areas were least likely to use sinus plain films or CT scans. Metropolitan-based teaching hospitals were less likely to use sinus plain film radiographs (OR ⫽ 0.81; p ⫽ 0.035) but more likely to order sinus CT scans (OR ⫽ 1.95; p ⬍ 0.001) on children with APS. In comparison with nonmetropolitan EDs, EDs in metropolitan nonteaching hospitals were more likely to order both sinus plain films (OR ⫽ 2.11; p ⬍ 0.001) and sinus CT scans (OR ⫽ 2.43; p ⬍ 0.001). From the standpoint of geographic use trends, EDs in the midwestern region were least likely to obtain either sinus plain films or CT scans for children with APS compared with EDs in the west, south, or northeast. EDs in the south were most likely to obtain a plain film radiograph (OR ⫽ 4.32; p ⬍ 0.001) and EDs in the northeast were most likely to obtain a sinus CT scan (OR ⫽ 9.02; p ⬍ 0.001).
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DISCUSSION The diagnosis of APS in children is made based on guidelineestablished criteria using clinical history and physical examination findings.4,5,18 The recommended role of imaging, primarily CT scan
imaging, is limited principally to those patients in whom orbital or intracranial complications are suspected. ED physicians treat children with APS from a wide variety of demographic, clinical, and socioeconomic backgrounds and are tasked with not only diagnosing routine cases of APS but also those with orbital and intracranial complications. Given this unique clinical care scenario, both patient- and hospital-specific factors associated with the differential use of ED imaging during the workup of APS were investigated. A cross-sectional study of a comprehensive nationwide database of ED visits admittedly has several limitations that must be considered in the context of the diversity in geography, patient population served, fiscal resources, time resources, and mix of acuity of care in EDs. Notably, this study is limited to data included in the 2008 NEDS. For example, certain demographic characteristics such as race are not included. Hospital characteristics are also made quite broadly, with teaching status tied directly to location in a metropolitan area, rather than ACGME residency or fellowship training criteria. Moreover, these data reflect 2008 ED practice patterns, which may have changed over the interim years. This study is also limited by the necessity to screen for patients based on ICD9 codes, which assumes accurate coding by ED staff. One benefit of studying a large national data set that includes ⬎100,000 children with APS is that the impact from a low frequency of inaccurate coding is minimized. Moreover, variation in aggressive diagnostic coding by ED physicians may affect the detection of comorbidities (or lack thereof). It is also impossible to definitively know why these imaging studies were ordered using a retrospective study design. Although imaging studies included in this study are limited to sinus-specific imaging protocols, analyses performed with inclusion of nonspecific imaging protocols of the head (as outlined in the Material and Methods section) led to qualitatively similar results as described previously. Additionally, the inclusion of
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25
Table 2 Clinicodemographic factors associated with sinus plain film during ED workup for APS*
Patient characteristics Age (yrs) Gender (male) Median income quartile 1 2 3 4 Primary payer Medicaid Private Uninsured No charge Other Hospital Characteristics Region Midwest South Northeast West Teaching status Nonmetropolitan Metropolitan teaching Metropolitan nonteaching
Univariate OR
Univariate p-Value
Multivariate OR
Multivariate p-Value
1.03 (1.02–1.04) —
⬍0.001 0.124
1.03 (1.02–1.05) 1.16 (1.01–1.34)
⬍0.001 0.032
1.0 0.83 (0.70–0.99) 1.04 (0.85–1.27) 1.93 (1.60–2.35)
— 0.037 0.697 ⬍0.001
1.0 — — 1.77 (1.43–2.20)
— 0.215 0.689 ⬍0.001
1.0 1.35 (1.16–1.57) 1.51 (1.21–1.88) 4.12 (1.30–13.07) 1.58 (1.15–2.15)
— ⬍0.001 ⬍0.001 0.016 0.004
1.0 1.23 (1.05–1.45) 1.30 (1.04–1.63) — 1.49 (1.07–2.09)
1.0 3.80 (3.02–4.78) 6.06 (4.70–7.81) 1.71 (1.16–2.53)
— ⬍0.001 ⬍0.001 0.007
1.0 — 2.19 (1.86–2.58)
— 0.105 ⬍0.001
O C 1.0 4.32 (3.42–5.46) 4.05 (3.12–5.26) 1.63 (1.10–2.53)
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1.0 0.81 (0.67–0.99) 2.11 (1.75–2.53)
— 0.012 0.022 0.107 0.019
— ⬍0.001 ⬍0.001 0.015 — 0.035 ⬍0.001
Variables not reaching statistical significance (p ⬍ 0.05) are not shown and include concurrent CRS, the presence of other comorbidities (HIV virus infection, lymphomas, leukemias, cystic fibrosis, and/or immune disorders) and the presence of APS complications. *ORs for reference variables are represented as 1.0, and ORs that are not statistically different from 1.0 are represented as “—.” HIV ⫽ human immunodeficiency virus; APS ⫽ acute pediatric sinusitis; ED ⫽ emergency department; CRS ⫽ chronic rhinosinusitis; OR ⫽ odds ratio.
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only imaging protocols specific to the paranasal sinuses likely increases the probability that the sinus imaging studied here was obtained for evaluation of sinusitis rather than nonsinusitis-related pathology. The findings of this study reflect practice patterns that are consistent with appropriate clinical decision making in several respects. Established guidelines have identified the role of advanced imaging,
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Figure 1. Bar plots depicting statistically significant odds ratios (ORs), with 95% confidence intervals, determined by multivariate logistic regression of (A) patient characteristics and (B) hospital characteristics associated with sinus plain film radiography in emergency departments (EDs) for children with acute sinusitis.
such as CT scan, in the setting of APS to be for evaluation of complications.4,5 In the present study, complications of APS are associated with the use of imaging—most notably sinus CT scans—in the workup of APS, as are risk factors for severe APS complications in the pediatric population such as older age19,20 and male gender.20,21 The study findings also reveal novel regional and socioeconomic associations with the use of ED imaging for children with APS. This
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Table 3 Clinicodemographic factors associated with sinus CT Scan during ED workup for APS*
Patient characteristics Age (yr) Gender (male) CRS APS complication Median income quartile 1 2 3 4 Primary payer Medicaid Private Uninsured No charge Other Hospital characteristics Region Midwest South Northeast West Teaching status Nonmetropolitan Metropolitan teaching Metropolitan nonteaching
Univariate OR
Univariate p-Value
Multivariate OR
Multivariate p-Value
1.08 (1.07–1.09) 1.69 (1.52–1.87) 5.23 (3.28–8.33) 5.42 (4.07–7.23)
⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001
1.08 (1.07–1.09) 1.82 (1.64–2.03) 3.05 (1.82–5.11) 3.03 (2.20–4.18)
⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001
1.0 0.81 (0.69–0.93) 1.87 (1.63–2.15) 3.76 (3.28–4.30)
— 0.004 ⬍0.001 ⬍0.001
1.0 0.76 (0.66–0.88) 1.45 (1.25–1.68) 2.03 (1.75–2.37)
1.0 2.10 (1.89–2.34) — 12.21 (6.77–22.03) 1.47 (1.14–1.90)
— ⬍0.001 0.883 ⬍0.001 0.003
1.0 1.43 (1.27–1.61) 0.72 (0.59–0.90) 6.63 (3.58–12.28) 1.46 (1.12–1.89)
1.0 3.43 (2.84–4.13) 11.53 (9.53–13.96) 4.56 (3.60–5.77)
— ⬍0.001 ⬍0.001 ⬍0.001
1.0 2.38 (2.06–2.76) 3.81 (3.29–4.42)
— ⬍0.001 ⬍0.001
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Y P — ⬍0.001 ⬍0.001 ⬍0.001 — ⬍0.001 0.003 ⬍0.001 0.005
1.0 4.43 (3.65–5.37) 9.02 (7.40–11.00) 3.61 (2.82–4.60)
— ⬍0.001 ⬍0.001 ⬍0.001
1.0 1.95 (1.67–2.29) 2.43 (2.06–2.87)
— ⬍0.001 ⬍0.001
The variable reflecting the presence of other comorbidities (HUV infection, lymphomas, leukemias, cystic fibrosis, and/or immune disorders) did not reach statistical significance (p ⬍ 0.05) and is therefore not shown. *ORs for reference variables are represented as 1.0, and ORs that are not statistically different from 1.0 are represented as “—.” HIV ⫽ human immunodeficiency virus; APS ⫽ acute pediatric sinusitis; ED ⫽ emergency department; CRS ⫽ chronic rhinosinusitis; OR ⫽ odds ratio; CT ⫽ computed tomography.
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Figure 2. Bar plots depicting statistically significant odds ratios (ORs), with 95% confidence intervals, determined by multivariate logistic regression of (A) patient characteristics and (B) hospital characteristics associated with sinus computed tomography (CT) in emergency departments (EDs) for children with acute sinusitis.
is in contrast to the aforementioned guidelines,4,5 which do not advocate the use of regional or socioeconomic characteristics in the clinical decision to order sinus imaging in children with acute sinusitis. In this study, EDs in the northeast and south are three to six times more likely to use imaging in the workup of APS than in the midwestern region. Because APS complications and patients’ comorbidi-
ties are included as independent predictor variables, the possibility of such a differential severity of APS presentation at different EDs is expected to be accounted for, at least partially, in the multivariate regressions. Other factors such as regional differences in reimbursement, liability, or medical culture may alternatively be responsible for the observed differences in imaging use. Additionally, despite the
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expectation that EDs in teaching hospitals would handle more severe cases, nonteaching hospitals in these metropolitan centers tended toward greater use of imaging, both plain films and CT scans. Future studies are needed to fully elucidate the nature of these differences in imaging use for children with APS in the ED setting. Although total ED expenses also include additional costs related to patients’ clinical conditions, these regional and hospital-specific differences in the practices of EDs with respect to the workup of APS present opportunities for education and cost savings. For example, although the use of sinus plain films is generally reported to offer no clinically significant insight into APS in the pediatric population,4 such use, nonetheless, continues with disparate regional usage. This approximately $700 additional expense may be reduced through education on the importance of clinical history with respect to specific upper respiratory tract symptoms and the duration thereof, as well as the questionable diagnostic value of sinus plain films in the evaluation of pediatric APS. Similarly, the use of CT scans, associated with an approximately $2800 increase in ED cost, should not be differentially used based on geographic location. Calling attention to such regional ED disparities in CT scan usage may enhance the efficacious diagnostic use of this imaging modality. Socioeconomic characteristics of children associated with the use of imaging in the workup of APS in EDs vary as well. Specifically, children with APS from families in the highest estimated median household income groups and children with private insurance were more likely to receive imaging, both sinus plain film radiographs and CT scans. In contrast, children who had Medicaid or were uninsured were the least likely to receive imaging. Previous studies have likewise reported a similar disparate workup of children in the ED setting based on socioeconomic status.13,22 Significant demographic, regional, and socioeconomic disparities in the use of imaging in the setting of APS in children clearly exist. These disparities do not necessarily correspond to a disadvantage for an underserved population but rather illustrate an inconsistent use of these imaging modalities associated with unexpected characteristics such as geographic or socioeconomic factors. Although the development and dissemination of clinical practice guidelines have been used to counteract disparities in care,23 barriers to universal adherence of clinical guidelines, such as lack of awareness or familiarity, nevertheless, remain.24 Consensus guidelines for the role of radiographic imaging in APS were established ⬎10 years ago by the American Academy of Pediatrics4 and remain effectively unchanged in the most recent consensus guidelines.5 In contrast to these guidelines, the present study shows that regional and socioeconomic characteristics are independently associated with ED use of sinus imaging in children with acute sinusitis.
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16. 17.
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CONCLUSIONS
The use of radiographic imaging in children with APS is inconsistent, with regional and socioeconomic disparities and potentially indicative of suboptimal and inefficient health care. The identification of these disparities in the care of APS will hopefully motivate future study to elucidate the underlying causes of these disparities and their ultimate correction. Such actions will serve to not only save health care dollars associated with inefficient care but also normalize care for those children with APS who may be underserved because of geographic or socioeconomic considerations.
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Wald ER, Guerra N, and Byers C. Upper respiratory tract infections in young children: Duration of and frequency of complications. Pediatrics 87:129–133, 1991.
Revai K, Dobbs LA, Nair S, et al. Incidence of acute otitis media and sinusitis complicating upper respiratory tract infection: The effect of age. Pediatrics 119:e1408–e1412, 2007. Shapiro DJ, Gonzales R, Cabana MD, and Hersh AL. National trends in visit rates and antibiotic prescribing for children with acute sinusitis. Pediatrics 127:28–34, 2011. American Academy of Pediatrics. Subcommittee on Management of Sinusitis and Committee on Quality Improvement. Clinical practice guideline: Management of sinusitis. Pediatrics 108:798–808, 2001. Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics 132:e262–e280. 2013. Chandran SK, and Higgins TS. Chapter 5: Pediatric rhinosinusitis: Definitions, diagnosis and management—An overview. Am J Rhinol Allergy 27(suppl 1):S16–S19, 2013. McAlister WH, Parker BR, Kushner DC, et al. Sinusitis in the pediatric population. American College of Radiology. ACR appropriateness criteria. Radiology 215(suppl):811–818, 2000. Diament MJ, Senac MO Jr, Gilsanz V, et al. Prevalence of incidental paranasal sinuses opacification in pediatric patients: A CT study. J Comput Assist Tomogr 11:426–431, 1987. Manning SC, Biavati MJ, and Phillips DL. Correlation of clinical sinusitis signs and symptoms to imaging findings in pediatric patients. Int J Pediatr Otorhinolaryngol 37:65–74, 1996. DeMuri GP, and Wald ER. Complications of acute bacterial sinusitis in children. Pediatr Infect Dis J 30:701–702, 2011. Dugar DR, Lander L, Mahalingam-Dhingra A, and Shah RK. Pediatric acute sinusitis: Predictors of increased resource utilization. Laryngoscope 120:2313–2321, 2010. Flores G, and Committee On Pediatric Research. Technical report— racial and ethnic disparities in the health and health care of children. Pediatrics 125:e979–e1020, 2010. Riera A, and Walker DM. The impact of race and ethnicity on care in the pediatric emergency department. Curr Opin Pediatr 22:284–289, 2010. Mechanic R, Coleman K, Dobson A. Teaching hospital costs: Implications for academic missions in a competitive market. JAMA. 280(11):1015–1019, 1998. Williams JR, Matthews MC, and Hassan M. Cost differences between academic and nonacademic hospitals: A case study of surgical procedures. Hosp Top 85:3–10, 2007. H-CUP. Statistical brief #108. Uninsured Hospital Stays, 2008. www.hcup-us.ahrq.gov/reports/statbriefs/sb108.jsp, April 2011. Harrell FE. Regression modeling strategies: With applications to linear models, logistic regression, and survival analysis. New York, NY: Springer, 568, 2001. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 54:e72–e112, 2012. Giannoni C, Sulek M, and Friedman EM. Intracranial complications of sinusitis: A pediatric series. Am J Rhinol 12:173–178, 1998. Germiller JA, Monin DL, Sparano AM, and Tom LW. Intracranial complications of sinusitis in children and adolescents and their outcomes. Arch Otolaryngol Head Neck Surg 132:969–976, 2006. Piatt JH Jr. Intracranial suppuration complicating sinusitis among children: An epidemiological and clinical study. J Neurosurg Pediatr 7:567–574, 2011. Hambrook JT, Kimball TR, Khoury P, and Cnota J. Disparities exist in the emergency department evaluation of pediatric chest pain. Congenit Heart Dis 5:285–291, 2010. Cabana MD, and Flores G. The role of clinical practice guidelines in enhancing quality and reducing racial/ethnic disparities in paediatrics. Paediatr Respir Rev 3:52–58, 2002. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 282:1458–1465, 1999. e
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ABSTRACT
Background: Acute pediatric sinusitis (APS) is a common complication of pediatric upper respiratory tract infections. Children with all degrees of APS severity may present to emergency departments (EDs) for evaluation and management. This study was designed to analyze the use of imaging in APS presenting to U.S. EDs. Methods: A cross-sectional analysis of the 2008 National Emergency Department Sample database was performed. One hundred one thousand six hundred sixty children, aged ⱕ18 years, assigned at least one ICD9 code for APS were identified. Current procedural terminology codes for sinus plain film radiographs, computed tomography (CT), and magnetic resonance imaging identified children who underwent sinus imaging. Association of performance of sinus imaging was sought with multiple predictor variables including clinicodemographic and hospital characteristics. Results: The use of any imaging was associated with older age (odds ratio [OR] ⫽ 1.07; p ⬍ 0.001), male gender (OR ⫽ 1.57; p ⬍ 0.001), and diagnosis of chronic rhinosinusitis (OR ⫽ 2.46; p ⬍ 0.001). Imaging was more common in metropolitan teaching (OR ⫽ 1.40;0 p ⬍ 0.001) and nonteaching (OR ⫽ 5.64; p ⬍ 0.001) hospitals. Markers of higher socioeconomic status—private health insurance (OR ⫽ 1.37; p ⬍ 0.001) and higher income level (OR ⫽ 1.96; p ⬍ 0.001)—were associated with greater use of imaging, especially CT scans. Conclusion: The use of ED imaging in APS is appropriately associated with factors known to be associated with APS complications. However, additional disparities with respect to regional and socioeconomic factors exist. Interventions to eliminate these health care disparities in use of imaging resources may lead to quality improvement in care and outcomes for APS. (Am J Rhinol Allergy 28, 23–28, 2014; doi: 10.2500/ajra.2014.28.3992)
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cute pediatric sinusitis (APS) is a common occurrence in the pediatric population, arising frequently as a complication of upper respiratory tract infection1,2 and accounting for approximately one million ambulatory visits annually.3 The diagnosis of APS is largely based on clinical grounds as per guidelines established by the American Academy of Pediatrics.4–6 Imaging is generally not recommended for the routine diagnosis of APS in children. This recommendation is based on the high positive predictive value of the clinical history and the nonspecificity of radiographic findings. The quality and interpretation of plain film radiography depends on both the cooperativeness of the child and the experience of the operator, either of which may predispose to an under- or overestimation of sinusitis.7 Even more advanced imaging such as computed tomography (CT) can be nonspecific. Paranasal sinus opacification and mucosal thickening are common incidental findings on review of sinus CT scans in children and adolescents.8,9 Approximately 50% of children may have sinus opacification on CT scan regardless of upper respiratory tract symptoms.9 The use of advanced imaging such as CT or magnetic resonance imaging (MRI) in the diagnostic workup of APS is therefore typically reserved for recurrent or chronic cases or in situations in which there is concern for orbital or intracranial complications.4,5,10 Children with both uncomplicated and complicated APS commonly present to emergency departments (EDs).3,11 Therefore, ED physicians are often faced with the task of determining which of these
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From the 1Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, 2Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, 3Department of Otolaryngology and Communication Enhancement, Children’s Hospital Boston, Boston, Massachusetts, and Divisions of 4Otolaryngology–Head and Neck Surgery and 5Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio The authors have no conflicts of interest to declare pertaining to this article Address correspondence to Ahmad R. Sedaghat, M.D., Ph.D., Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114 E-mail address: [email protected] Copyright © 2014, OceanSide Publications, Inc., U.S.A.
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children would benefit from imaging. In this study, the use of imaging in the diagnosis of APS in children is studied through a crosssectional analysis of a comprehensive national database of ED visits. Previous studies have shown that lower socioeconomic status may be associated with a disparate quality of health care for children,12 including in the ED setting.13 Hospital-specific factors such as geographic location and academic affiliation can be associated with disparate health care costs as well.14,15 By characterizing patient-specific and hospital-specific factors associated with the use of imaging in the diagnostic workup of APS, substantial disparities in health care use and costs may be identified and ideally minimized.
MATERIALS AND METHODS Screening for Study Subjects The 2008 National Emergency Department Sample (NEDS) database, a comprehensive and representative nationwide database of patient and hospital characteristics associated with ED visits in the United States, was screened for APS by searching for all patients ⬍18 years of age with at least one ICD9 code for acute sinusitis (461.0, 461.1, 461.2, 461.3, 461.8, and 461.9) assigned to any of the first five diagnoses. A total of 101,660 pediatric patients were found. Children were further screened for the use of imaging by searching for a concomitant current procedural terminology code for sinus plain film (70210 or 70220), sinus CT scan (70480, 70481, 70482, 70486, 70487, or 70488), or sinus MRI (70540 or 70543). Patient demographic characteristics of age and gender were extracted, as were insurance types and median income levels by zip code (referred to as estimated median household income level in the text and as previously described in the Uninsured Hospital Stays report),16 the latter serving as proxy measures for socioeconomic status. Insurance type was categorized16 as (1) Medicaid, which includes both fee-for-service and managed care Medicaid plans; (2) private, which includes Blue Cross and commercial carriers, as well as private Health Maintenance Organizations and Preferred Pro-
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23
vider Organizations; (3) uninsured patients where “self-pay” was listed as the primary payer; (4) no charge, which consists of patients for whose ED visit the hospital did not charge the patient or insurer; and (5) other, which includes other governmental programs such as TRICARE/CHAMPUS, CHAMPVA and Title V. For each patient, total ED costs were tabulated in and directly obtained from the NEDS database. Comorbidities such as chronic rhinosinusitis (CRS; ICD9 code 473.0, 473.1, 473.2, 473.3, 473.8, or 473.9) were considered, as were human immunodeficiency virus (HIV) infection (Clinical Classifications Software [CCS] code 5), lymphoma (CCS codes 37 or 38), leukemia (CCS code 39), cystic fibrosis (CCS code 56), and immune disorders (CCS code 57, associated with all ICD9 codes for “disorders involving the immune mechanism,” such as deficiencies of humoral immunity, deficiencies of cellular immunity, or combined immune deficiency). These comorbid diagnoses were considered to be caused by their impact on the immune system and concern that they may accelerate the clinical course of APS, influencing emergency physicians to obtain additional imaging. Complications of APS were identified by screening for the following ICD9 codes: preseptal periorbital cellulitis (373.13), orbital complications including orbital cellulitis and abscess (376.0, 376.01, 376.02, and 376.03), and intracranial complications including intracranial epidural and subdural abscesses (324.0) and cavernous sinus thrombosis (325.0). Hospital characteristics including U.S. region and teaching status were extracted directly from the NEDS. Regions were categorized as northeast, south, midwest, and west, and teaching status was categorized as nonmetropolitan, metropolitan teaching, and metropolitan nonteaching, each as previously defined in the NEDS.16
age of these patients was 8.6 years (SD, 5.7 years) with a gender composition of 50.1% male and 49.9% female patients. Sinus plain film radiographs were performed on 852 children (0.8%), and 1607 patients underwent a sinus CT scan (1.6%). No children were recorded as having undergone MRI of the sinuses. Although the average charge associated with children with APS who did not undergo any imaging was $751, the average ED charges associated with children who underwent plain film radiography and CT scan were $1563 and $3534, respectively. Diagnoses of CRS or other comorbidities such as HIV infection, lymphoma, leukemia, cystic fibrosis, or immune disorders were made in ⬍1% of patients (Table 1). APS complications were diagnosed in 696 (0.7%) patients. Medicaid (50%) and private insurance (35.9%) were the most common primary insurance types listed. Both patient-specific and hospital-specific characteristics of children with APS who either did or did not undergo sinus imaging (Table 1) were noted and further explored for statistically significant association.
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Strategies to Reduce Confounding Effects Statistical analyses were additionally performed using only patients who had acute sinusitis ICD9 codes as the primary (first) diagnosis code or as 1 of all 15 diagnosis codes with no qualitative change to the reported results (calculated for patients with an acute sinusitis ICD9 as 1 of the first 5 diagnosis codes). Similarly, analyses were performed including nonspecific imaging protocols: CT head (70450, 70460, and 70470), x ray of the skull (70250 and 70260), x ray of the orbits (70200), and x ray of the facial bones (70140 and 70150). In all cases, these different analyses produced qualitatively similar results as those presented later in text. Additionally, patient comorbidities and concurrent diagnosis of APS complications (e.g., preseptal cellulitis, orbital, and intracranial abscesses) were included in all multivariate analyses to account for patient illness and APS severity in the usage of imaging.
RESULTS Characteristics of Study Subjects Overall, 101,660 pediatric patients were diagnosed with APS in EDs nationwide, with average ED charges of $804 per patient. The average
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Characteristics associated with ED imaging of the paranasal sinuses by plain film radiography or CT scan were evaluated. Patient-specific characteristics noted to be statistically associated with the use of imaging included older age (OR ⫽ 1.07; p ⬍ 0.001) and male gender (OR ⫽ 1.57; p ⬍ 0.001). The diagnosis of CRS was also associated with an increased use of imaging (OR ⫽ 2.20; p ⬍ 0.001), whereas comorbidities such as HIV infection, lymphoma, leukemia, cystic fibrosis, or immune system disorders were not. As would be expected, complications of APS were also associated with the use of imaging (OR ⫽ 2.25; p ⬍ 0.001). Children from higher-income groups tended to receive imaging studies more often, with the greatest difference between those children from the highest and lowest income groups (OR ⫽ 1.98; p ⬍ 0.001). Moreover, patients with Medicaid and those who were uninsured were least likely to receive imaging. Patients with private insurance (OR ⫽ 1.38; p ⬍ 0.001), those who were not billed by the hospital (designated “no chargef”) for their visit (OR ⫽ 5.62; p ⬍ 0.001), and other types of insurance (e.g., TRICARE/CHAMPUS, CHAMPVA, Title V and other government programs; OR ⫽ 1.49; p ⬍ 0.001) were all more likely to receive imaging than those patients who had Medicaid. Some diversity in the use of ED imaging was associated with hospital characteristics. Patients presenting to metropolitan teaching hospitals (OR ⫽ 1.39; p ⬍ 0.001) and, to a greater extent, metropolitan nonteaching hospitals (OR ⫽ 2.22; p ⬍ 0.001) were more likely to receive imaging compared with those presenting to EDs in nonmetropolitan areas. Regionally, midwestern EDs were least likely to use imaging in the workup of APS compared with EDs in the west (OR ⫽ 2.88; p ⬍ 0.001), south (OR ⫽ 4.45; p ⬍ 0.001), and northeast (OR ⫽ 6.92; p ⬍ 0.001). Subgroup analysis was performed to further evaluate associations between patient- and hospital-specific factors with the use of sinus plain film radiographs (Table 2 and Fig. 1) or CT (Table 3 and Fig. 2). Older children were more likely to undergo sinus plain film radiography (OR ⫽ 1.03; p ⬍ 0.001; Fig. 1 A) and CT scans (OR ⫽ 1.08; p ⬍ 0.001; Fig. 2 A). Boys were also more likely to undergo sinus plain film radiography (OR ⫽ 1.16; p ⫽ 0.032) and CT scan imaging (OR ⫽ 1.82; p ⬍ 0.001). Comorbid conditions such as HIV infection, lymphoma, leukemia, cystic fibrosis, or immune system disorders were not associated with the use of sinus plain films or CT scan imaging. Although also not associated with sinus plain films, a concomitant diagnosis of CRS (OR ⫽ 3.05; p ⬍ 0.001) or a complication of APS (OR ⫽ 3.03; p ⬍ 0.001) was associated with the use of CT scan imaging. Similar to the use of imaging in general, children from the highest estimated median household income level were more likely to undergo a sinus plain film (OR ⫽ 1.77; p ⬍ 0.001; Fig. 1 A) or CT (OR ⫽
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Statistical Analysis All analyses were performed with the statistical software R (www.r-project.org). Associations between the ascertainment of imaging and predictor variables were determined with the logistic regression function lrm() in the rms package.17 Univariate logistic regression was performed for each predictor variable. Multivariate logistical analysis was performed using all predictor variables. In the multivariate model, significant predictors were identified via backward elimination, using a p-value cutoff of 0.100. Cross-validation was performed through bootstrapping of the data set using the validate function from the rms package over 100 iterations. For each variable retained in the final model, a p-value and a log-odds ratio (OR) were calculated.
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Patient and Hospital Characteristics Associated with Radiographic Imaging
January–February 2014, Vol. 28, No. 1
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Table 1 Clinicodemographic factors of pediatric patients diagnosed with APS in the ED All
Sinus Plain Film No
Patient characteristics Number of patients Fraction of patients (%) Age (yr) Gender (% male) CRS (%) Other comorbidities* (%) Median income# Primary payer (%) Medicaid Private Uninsured No charge Other ED charges ($) Hospital characteristics Region (%) South Northeast Midwest West Teaching status (%) Nonmetropolitan Metropolitan teaching Metropolitan nonteaching
101,660 100 8.6 50.1 0.3 0.2 2.0
100,808 99.2 8.6 50.1 0.3 0.2 2.0
50.2 36.0 9.7 0.1 4.0 804.41
50.3 36.0 9.7 0.1 4.0 797.59
49.9 12.2 30.3 7.6
49.8 12.1 30.4 7.7
34.2 40.8 25.0
T 34.2 40.9 24.9
CT Scan Yes
852 0.8 9.6 52.7 0.5 0.0 2.2
No 100,053 98.4 8.5 49.9 0.3 0.2 2.0
Yes 1607 1.6 10.9 62.6 1.6 0.3 2.5
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41.9 40.5 12.2 0.4 5.3 1563.25
50.4 35.7 9.8 0.1 4.0 758.35
35.9 53.2 6.8 0.8 4.2 3534.14
61.8 24.0 9.9 4.3
50.0 11.8 30.6 7.6
45.6 36.8 8.4 9.2
27.7 28.5 43.8
34.5 40.8 24.7
15.2 43.5 41.3
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*Other comorbidities: HIV infection, lymphomas, leukemias, cystic fibrosis, and/or immune disorders. #Quartile classification (with respect to the entire United States) of the estimated median household income of residents in the patient’s zip code. HIV ⫽ human immunodeficiency virus; APS ⫽ acute pediatric sinusitis; ED ⫽ emergency department; CRS ⫽ chronic rhinosinusitis.
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2.03; p ⬍ 0.001; Fig. 2 A) than children from the lowest household income level. Children with Medicaid or no insurance at all were least likely to undergo either type of imaging, and children with private health insurance were more likely to receive either a sinus plain film radiograph (OR ⫽ 1.23; p ⫽ 0.012) or CT scan (OR ⫽ 1.43; p ⬍ 0.001). Similarly, children on other governmental insurance programs were more likely to receive a sinus plain film radiograph (OR ⫽ 1.49; p ⫽ 0.019) or CT scan (OR ⫽ 1.46; p ⬍ 0.001). Compared with children with Medicaid, children who were uninsured were more likely to receive a sinus plain film (OR ⫽ 1.30; p ⫽ 0.022) but less likely to receive a sinus CT scan (OR ⫽ 0.72; p ⫽ 0.003). Hospital characteristics were also associated with the use of sinus plain films (Fig. 1 B) or CT scans (Fig. 2 B) for children with APS. EDs located in nonmetropolitan areas were least likely to use sinus plain films or CT scans. Metropolitan-based teaching hospitals were less likely to use sinus plain film radiographs (OR ⫽ 0.81; p ⫽ 0.035) but more likely to order sinus CT scans (OR ⫽ 1.95; p ⬍ 0.001) on children with APS. In comparison with nonmetropolitan EDs, EDs in metropolitan nonteaching hospitals were more likely to order both sinus plain films (OR ⫽ 2.11; p ⬍ 0.001) and sinus CT scans (OR ⫽ 2.43; p ⬍ 0.001). From the standpoint of geographic use trends, EDs in the midwestern region were least likely to obtain either sinus plain films or CT scans for children with APS compared with EDs in the west, south, or northeast. EDs in the south were most likely to obtain a plain film radiograph (OR ⫽ 4.32; p ⬍ 0.001) and EDs in the northeast were most likely to obtain a sinus CT scan (OR ⫽ 9.02; p ⬍ 0.001).
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DISCUSSION The diagnosis of APS in children is made based on guidelineestablished criteria using clinical history and physical examination findings.4,5,18 The recommended role of imaging, primarily CT scan
imaging, is limited principally to those patients in whom orbital or intracranial complications are suspected. ED physicians treat children with APS from a wide variety of demographic, clinical, and socioeconomic backgrounds and are tasked with not only diagnosing routine cases of APS but also those with orbital and intracranial complications. Given this unique clinical care scenario, both patient- and hospital-specific factors associated with the differential use of ED imaging during the workup of APS were investigated. A cross-sectional study of a comprehensive nationwide database of ED visits admittedly has several limitations that must be considered in the context of the diversity in geography, patient population served, fiscal resources, time resources, and mix of acuity of care in EDs. Notably, this study is limited to data included in the 2008 NEDS. For example, certain demographic characteristics such as race are not included. Hospital characteristics are also made quite broadly, with teaching status tied directly to location in a metropolitan area, rather than ACGME residency or fellowship training criteria. Moreover, these data reflect 2008 ED practice patterns, which may have changed over the interim years. This study is also limited by the necessity to screen for patients based on ICD9 codes, which assumes accurate coding by ED staff. One benefit of studying a large national data set that includes ⬎100,000 children with APS is that the impact from a low frequency of inaccurate coding is minimized. Moreover, variation in aggressive diagnostic coding by ED physicians may affect the detection of comorbidities (or lack thereof). It is also impossible to definitively know why these imaging studies were ordered using a retrospective study design. Although imaging studies included in this study are limited to sinus-specific imaging protocols, analyses performed with inclusion of nonspecific imaging protocols of the head (as outlined in the Material and Methods section) led to qualitatively similar results as described previously. Additionally, the inclusion of
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25
Table 2 Clinicodemographic factors associated with sinus plain film during ED workup for APS*
Patient characteristics Age (yrs) Gender (male) Median income quartile 1 2 3 4 Primary payer Medicaid Private Uninsured No charge Other Hospital Characteristics Region Midwest South Northeast West Teaching status Nonmetropolitan Metropolitan teaching Metropolitan nonteaching
Univariate OR
Univariate p-Value
Multivariate OR
Multivariate p-Value
1.03 (1.02–1.04) —
⬍0.001 0.124
1.03 (1.02–1.05) 1.16 (1.01–1.34)
⬍0.001 0.032
1.0 0.83 (0.70–0.99) 1.04 (0.85–1.27) 1.93 (1.60–2.35)
— 0.037 0.697 ⬍0.001
1.0 — — 1.77 (1.43–2.20)
— 0.215 0.689 ⬍0.001
1.0 1.35 (1.16–1.57) 1.51 (1.21–1.88) 4.12 (1.30–13.07) 1.58 (1.15–2.15)
— ⬍0.001 ⬍0.001 0.016 0.004
1.0 1.23 (1.05–1.45) 1.30 (1.04–1.63) — 1.49 (1.07–2.09)
1.0 3.80 (3.02–4.78) 6.06 (4.70–7.81) 1.71 (1.16–2.53)
— ⬍0.001 ⬍0.001 0.007
1.0 — 2.19 (1.86–2.58)
— 0.105 ⬍0.001
O C 1.0 4.32 (3.42–5.46) 4.05 (3.12–5.26) 1.63 (1.10–2.53)
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1.0 0.81 (0.67–0.99) 2.11 (1.75–2.53)
— 0.012 0.022 0.107 0.019
— ⬍0.001 ⬍0.001 0.015 — 0.035 ⬍0.001
Variables not reaching statistical significance (p ⬍ 0.05) are not shown and include concurrent CRS, the presence of other comorbidities (HIV virus infection, lymphomas, leukemias, cystic fibrosis, and/or immune disorders) and the presence of APS complications. *ORs for reference variables are represented as 1.0, and ORs that are not statistically different from 1.0 are represented as “—.” HIV ⫽ human immunodeficiency virus; APS ⫽ acute pediatric sinusitis; ED ⫽ emergency department; CRS ⫽ chronic rhinosinusitis; OR ⫽ odds ratio.
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only imaging protocols specific to the paranasal sinuses likely increases the probability that the sinus imaging studied here was obtained for evaluation of sinusitis rather than nonsinusitis-related pathology. The findings of this study reflect practice patterns that are consistent with appropriate clinical decision making in several respects. Established guidelines have identified the role of advanced imaging,
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Figure 1. Bar plots depicting statistically significant odds ratios (ORs), with 95% confidence intervals, determined by multivariate logistic regression of (A) patient characteristics and (B) hospital characteristics associated with sinus plain film radiography in emergency departments (EDs) for children with acute sinusitis.
such as CT scan, in the setting of APS to be for evaluation of complications.4,5 In the present study, complications of APS are associated with the use of imaging—most notably sinus CT scans—in the workup of APS, as are risk factors for severe APS complications in the pediatric population such as older age19,20 and male gender.20,21 The study findings also reveal novel regional and socioeconomic associations with the use of ED imaging for children with APS. This
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Table 3 Clinicodemographic factors associated with sinus CT Scan during ED workup for APS*
Patient characteristics Age (yr) Gender (male) CRS APS complication Median income quartile 1 2 3 4 Primary payer Medicaid Private Uninsured No charge Other Hospital characteristics Region Midwest South Northeast West Teaching status Nonmetropolitan Metropolitan teaching Metropolitan nonteaching
Univariate OR
Univariate p-Value
Multivariate OR
Multivariate p-Value
1.08 (1.07–1.09) 1.69 (1.52–1.87) 5.23 (3.28–8.33) 5.42 (4.07–7.23)
⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001
1.08 (1.07–1.09) 1.82 (1.64–2.03) 3.05 (1.82–5.11) 3.03 (2.20–4.18)
⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001
1.0 0.81 (0.69–0.93) 1.87 (1.63–2.15) 3.76 (3.28–4.30)
— 0.004 ⬍0.001 ⬍0.001
1.0 0.76 (0.66–0.88) 1.45 (1.25–1.68) 2.03 (1.75–2.37)
1.0 2.10 (1.89–2.34) — 12.21 (6.77–22.03) 1.47 (1.14–1.90)
— ⬍0.001 0.883 ⬍0.001 0.003
1.0 1.43 (1.27–1.61) 0.72 (0.59–0.90) 6.63 (3.58–12.28) 1.46 (1.12–1.89)
1.0 3.43 (2.84–4.13) 11.53 (9.53–13.96) 4.56 (3.60–5.77)
— ⬍0.001 ⬍0.001 ⬍0.001
1.0 2.38 (2.06–2.76) 3.81 (3.29–4.42)
— ⬍0.001 ⬍0.001
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1.0 4.43 (3.65–5.37) 9.02 (7.40–11.00) 3.61 (2.82–4.60)
— ⬍0.001 ⬍0.001 ⬍0.001
1.0 1.95 (1.67–2.29) 2.43 (2.06–2.87)
— ⬍0.001 ⬍0.001
The variable reflecting the presence of other comorbidities (HUV infection, lymphomas, leukemias, cystic fibrosis, and/or immune disorders) did not reach statistical significance (p ⬍ 0.05) and is therefore not shown. *ORs for reference variables are represented as 1.0, and ORs that are not statistically different from 1.0 are represented as “—.” HIV ⫽ human immunodeficiency virus; APS ⫽ acute pediatric sinusitis; ED ⫽ emergency department; CRS ⫽ chronic rhinosinusitis; OR ⫽ odds ratio; CT ⫽ computed tomography.
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Figure 2. Bar plots depicting statistically significant odds ratios (ORs), with 95% confidence intervals, determined by multivariate logistic regression of (A) patient characteristics and (B) hospital characteristics associated with sinus computed tomography (CT) in emergency departments (EDs) for children with acute sinusitis.
is in contrast to the aforementioned guidelines,4,5 which do not advocate the use of regional or socioeconomic characteristics in the clinical decision to order sinus imaging in children with acute sinusitis. In this study, EDs in the northeast and south are three to six times more likely to use imaging in the workup of APS than in the midwestern region. Because APS complications and patients’ comorbidi-
ties are included as independent predictor variables, the possibility of such a differential severity of APS presentation at different EDs is expected to be accounted for, at least partially, in the multivariate regressions. Other factors such as regional differences in reimbursement, liability, or medical culture may alternatively be responsible for the observed differences in imaging use. Additionally, despite the
American Journal of Rhinology & Allergy
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expectation that EDs in teaching hospitals would handle more severe cases, nonteaching hospitals in these metropolitan centers tended toward greater use of imaging, both plain films and CT scans. Future studies are needed to fully elucidate the nature of these differences in imaging use for children with APS in the ED setting. Although total ED expenses also include additional costs related to patients’ clinical conditions, these regional and hospital-specific differences in the practices of EDs with respect to the workup of APS present opportunities for education and cost savings. For example, although the use of sinus plain films is generally reported to offer no clinically significant insight into APS in the pediatric population,4 such use, nonetheless, continues with disparate regional usage. This approximately $700 additional expense may be reduced through education on the importance of clinical history with respect to specific upper respiratory tract symptoms and the duration thereof, as well as the questionable diagnostic value of sinus plain films in the evaluation of pediatric APS. Similarly, the use of CT scans, associated with an approximately $2800 increase in ED cost, should not be differentially used based on geographic location. Calling attention to such regional ED disparities in CT scan usage may enhance the efficacious diagnostic use of this imaging modality. Socioeconomic characteristics of children associated with the use of imaging in the workup of APS in EDs vary as well. Specifically, children with APS from families in the highest estimated median household income groups and children with private insurance were more likely to receive imaging, both sinus plain film radiographs and CT scans. In contrast, children who had Medicaid or were uninsured were the least likely to receive imaging. Previous studies have likewise reported a similar disparate workup of children in the ED setting based on socioeconomic status.13,22 Significant demographic, regional, and socioeconomic disparities in the use of imaging in the setting of APS in children clearly exist. These disparities do not necessarily correspond to a disadvantage for an underserved population but rather illustrate an inconsistent use of these imaging modalities associated with unexpected characteristics such as geographic or socioeconomic factors. Although the development and dissemination of clinical practice guidelines have been used to counteract disparities in care,23 barriers to universal adherence of clinical guidelines, such as lack of awareness or familiarity, nevertheless, remain.24 Consensus guidelines for the role of radiographic imaging in APS were established ⬎10 years ago by the American Academy of Pediatrics4 and remain effectively unchanged in the most recent consensus guidelines.5 In contrast to these guidelines, the present study shows that regional and socioeconomic characteristics are independently associated with ED use of sinus imaging in children with acute sinusitis.
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CONCLUSIONS
The use of radiographic imaging in children with APS is inconsistent, with regional and socioeconomic disparities and potentially indicative of suboptimal and inefficient health care. The identification of these disparities in the care of APS will hopefully motivate future study to elucidate the underlying causes of these disparities and their ultimate correction. Such actions will serve to not only save health care dollars associated with inefficient care but also normalize care for those children with APS who may be underserved because of geographic or socioeconomic considerations.
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January–February 2014, Vol. 28, No. 1
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