racial and ethnic differences in emergency department

Original Investigation | Pediatrics

Racial and Ethnic Differences in Emergency Department Diagnostic Imagingat US Children’s Hospitals, 2016-2019Jennifer R. Marin, MD, MSc; Jonathan Rodean, MPP; Matt Hall, PhD; Elizabeth R. Alpern, MD, MSCE; Paul L. Aronson, MD, MHS; Pradip P. Chaudhari, MD;Eyal Cohen, MD, MSc; Stephen B. Freedman, MDCM, MSc; Rustin B. Morse, MD, MMM; Alon Peltz, MD, MBA; Margaret Samuels-Kalow, MD, MPhil, MSHP;Samir S. Shah, MD, MSCE; Harold K. Simon, MD, MBA; Mark I. Neuman, MD, MPH

Abstract

IMPORTANCE Diagnostic imaging is frequently performed as part of the emergency department(ED) evaluation of children. Whether imaging patterns differ by race and ethnicity is unknown.

OBJECTIVE To evaluate racial and ethnic differences in the performance of common ED imagingstudies and to examine patterns across diagnoses.

DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study evaluated visits by patientsyounger than 18 years to 44 US children’s hospital EDs from January 1, 2016, through December31, 2019.

EXPOSURES Non-Hispanic Black and Hispanic compared with non-Hispanic White race/ethnicity.

MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of visits for eachrace/ethnicity group with at least 1 diagnostic imaging study, defined as plain radiography, computedtomography, ultrasonography, and magnetic resonance imaging. The major diagnostic categoriesclassification system was used to examine race/ethnicity differences in imaging rates by diagnoses.

RESULTS A total of 13 087 522 visits by 6 230 911 children and adolescents (mean [SD] age, 5.8 [5.2]years; 52.7% male) occurred during the study period. Diagnostic imaging was performed during3 689 163 visits (28.2%). Imaging was performed in 33.5% of visits by non-Hispanic White patientscompared with 24.1% of visits by non-Hispanic Black patients (odds ratio [OR], 0.60; 95% CI, 0.60-0.60) and 26.1% of visits by Hispanic patients (OR, 0.66; 95% CI, 0.66-0.67). Adjusting forconfounders, visits by non-Hispanic Black (adjusted OR, 0.82; 95% CI, 0.82-0.83) and Hispanic(adjusted OR, 0.87; 95% CI, 0.87-0.87) patients were less likely to include any imaging studycompared with visits by non-Hispanic White patients. Limiting the analysis to only visits bynonhospitalized patients, the adjusted OR for imaging was 0.79 (95% CI, 0.79-0.80) for visits bynon-Hispanic Black patients and 0.84 (95% CI, 0.84-0.85) for visits by Hispanic patients. Resultswere consistent in analyses stratified by public and private insurance groups and did not materiallydiffer by diagnostic category.

CONCLUSIONS AND RELEVANCE In this study, non-Hispanic Black and Hispanic children were lesslikely to receive diagnostic imaging during ED visits compared with non-Hispanic White children.Further investigation is needed to understand and mitigate these potential disparities in health caredelivery and to evaluate the effect of these differential imaging patterns on patient outcomes.

JAMA Network Open. 2021;4(1):e2033710. doi:10.1001/jamanetworkopen.2020.33710

Key PointsQuestion Does the use of diagnostic

imaging for children receiving care in US

pediatric emergency departments (EDs)

differ by race and ethnicity?

Findings This multicenter cross-

sectional study of more than 13 million

pediatric ED visits to 44 children’s

hospitals demonstrated that

non-Hispanic Black and Hispanic

patients were less likely to undergo

diagnostic imaging compared with

non-Hispanic White patients.

Meaning In these findings, race and

ethnicity appear to be independently

associated with imaging decisions in the

pediatric ED, highlighting the need to

better understand and mitigate these

disparities.

+ Invited Commentary

+ Supplemental content

Author affiliations and article information arelisted at the end of this article.

Open Access. This is an open access article distributed under the terms of the CC-BY License.

JAMA Network Open. 2021;4(1):e2033710. doi:10.1001/jamanetworkopen.2020.33710 (Reprinted) January 29, 2021 1/14

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Introduction

In 2010, the American Academy of Pediatrics published a landmark report highlighting “extensive,pervasive, and persistent” disparities in pediatric health care delivery and quality.1(p1014) An importantdeterminant of health care quality is the appropriate use of diagnostic testing for evaluating acuteillness in children. In particular, radiologic imaging for pediatric patients is commonly used in theemergency department (ED) setting, with one-third of all visits including at least 1 imaging study.2 Inaddition to the many benefits, imaging also carries risks and considerations regarding resource use,including radiation exposure,3 incidental findings leading to follow-up visits and testing,4 increasedED length of stay,5,6 and cost.7 Therefore, differential use of imaging studies across racial and ethnicgroups suggests that worse care is being delivered to 1 or more groups.

Studies of racial and ethnic differences in pediatric diagnostic imaging8-12 have shown higherrates of selected imaging use in non-Hispanic White children compared with non-White children.However, these studies were limited in scope, focusing on a single imaging modality for a specificcondition. One study of ED visits among adults demonstrated that non-Hispanic Black patients wereless likely to have radiography, computed tomography (CT), and magnetic resonance imaging (MRI)studies performed.13 These patterns in adults may not be relevant for children, because imagingstrategies, scope of presenting complaints and diagnoses, and often severity of illness differ betweenadults and children.14-16

In our previous work,6 we observed that non-Hispanic White children had higher odds ofreceiving advanced imaging compared with non-White patients. We sought to further explore thisfinding by evaluating whether racial and ethnic differences exist across imaging modalities andwhether these differences persist across diagnoses and by insurance type.

Methods

Data Source and Study DesignThis multicenter cross-sectional study of the Pediatric Health Information System (PHIS) includesadministrative data from 52 tertiary care US children’s hospitals. Participating hospitals are located in27 states plus Washington, DC, representing 17 of the 20 major metropolitan areas. The Children’sHospital Association maintains the PHIS and ensures data quality and control through a joint effortwith participating hospitals. We included 44 EDs in our study after excluding 8 that did notcontribute complete ED data during the study period. We included all ED visits from January 1, 2016,through December 31, 2019, by patients younger than 18 years. This period was selected to enableuse of the International Statistical Classification of Diseases, 10th Revision, Clinical Modification(ICD-10-CM), which was adopted in 2015 across participating sites. This study followed theStrengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelinefor cross-sectional studies.17 The University of Pittsburgh institutional review board determined thatthe study protocol was not human subjects research and therefore was exempt from review andinformed consent.

Variables and Outcome MeasuresThe primary outcome was the proportion of ED visits during which at least 1 diagnostic imaging test,defined as radiography, ultrasonography, CT, and MRI, was performed. These modalities wereselected because they represent the most frequently performed diagnostic imaging studies in theemergency setting.15 Diagnostic imaging in the PHIS is identified through billing codes and includesthe date of imaging. However, for patients who are admitted from the ED, the data source does notdistinguish between imaging performed in the ED and imaging performed as an inpatient on thesame date. Therefore, and in keeping with prior work,6,18 we defined imaging for admitted patientsas follows: if ED arrival time was before 6 PM, we attributed imaging to the ED if it occurred on the day

JAMA Network Open | Pediatrics Racial and Ethnic Differences in ED Diagnostic Imaging at US Children’s Hospitals



https://www.equator-network.org/reporting-guidelines/strobe/

of arrival; if ED arrival time was after 6 PM, we attributed imaging to the ED if it occurred on the dayof arrival or the next day.

The exposure of interest was documented race and ethnicity. In the PHIS, race and ethnicity areincluded as 2 distinct variables, which were collapsed into a single variable.19 Hospitals submit raceand ethnicity data to the PHIS for each visit according to hospital-specific practices, which includeparent/guardian self-report at the time of arrival or hospital registration assignment. We categorizedrace and ethnicity into 4 mutually exclusive groups: non-Hispanic White, non-Hispanic Black,Hispanic of any race, and other.20 The category of other included American Indian (0.2%), Asian(2.5%), Native Hawaiian (0.2%), multiracial (1.2%), other race (5.5%), and missing (2.0%). Given thesmall sample size and heterogeneity of the other group, we focused our analyses on the differencescomparing non-Hispanic White patients with non-Hispanic Black and Hispanic patients.

We also analyzed demographic, clinical, and visit covariates that either have been shown to beassociated with race/ethnicity and imaging or are part of the behavioral model described byAnderson et al,21 a conceptual framework for evaluating and analyzing access and equity in healthcare, including predisposing, enabling, and need factors. Specifically, we evaluated patient age andsex,22 insurance,23 time and day of visit,22,24 household income,25,26 distance from the hospital,27

complex chronic conditions,26 3-day revisit,28,29 hospitalization (including intensive care unitadmission),26 visit diagnosis,13 and year.6 We stratified patient age into clinically meaningfulcategories (<1, 1-4, 5-12, and 13-17 years) and defined the visit day as weekend vs weekday and arrivaltime as daytime (8:00 AM to 3:59 PM), evening (4:00 to 11:59 PM), or overnight (12:00 to 7:59 AM).30

Median neighborhood household income, presented as quartiles, was based on patient home 5-digitzip code in the PHIS and mapped to the American Community Survey 5-year data for 2014 to 2018.31

Distance to the hospital was based on the distance between the centroids of patient home andhospital 5-digit zip codes. We defined complex chronic conditions using the system-basedclassification scheme by Feudtner et al,32 which has been updated to accommodate ICD-10-CMimplementation, including neonatal, technology dependence, and organ transplant categories. Avisit was considered to be a 3-day revisit if an ED visit occurred within 3 prior calendar days. Given thelarge number of ICD-10-CM codes, we used the major diagnostic category classification system toclassify visits into 1 of 26 mutually exclusive major organ system–based categories and thereby definethe visit diagnosis.33 These diagnostic categories are based on the All Patient Refined–DiagnosisRelated Groups classification system, which is based on the principal discharge ICD-10-CM diagnosisfor the visit33 (eTable 1 in the Supplement). As an additional analysis, we also analyzed the top 10principal ICD-10-CM codes responsible for the highest volume of encounters with imaging.

Statistical AnalysisWe summarized data with percentages and used Rao-Scott χ2 tests, adjusting for clustering withinhospitals, to compare categorical data across race/ethnicity groups. We constructed groups ofgeneralized linear models, including the covariates described above, with a binomial distribution anda random effect for hospital, evaluating the independent association of race/ethnicity on overall andindividual imaging modalities (ie, radiography, CT, ultrasonography, and MRI). Because of the strongbasis for the multicollinearity among race/ethnicity, insurance type, and median neighborhoodincome,34,35 we performed a variance inflation factor analysis using a cutoff of 5.36 For this analysis,income was estimated by race and payer, suggesting the presence of multicollinearity; therefore, weexcluded income from all models. Given the large differences in insurance coverage by race andethnicity37 and because of the potential interaction between race and ethnicity and insurance, wereplicated the modeling stratified by insurance type. The PHIS does not include data on illnessseverity (eg, Emergency Severity Index); in addition, non-Hispanic White race may be independentlyassociated with lower38 or higher39 risk of hospitalization. Therefore, to assess the validity of ourfindings, we performed a separate analysis in which we limited the cohort to visits by nonhospitalizedchildren.





We used generalized linear modeling (incorporating the covariates described previously) toestimate diagnostic category–specific adjusted odds ratios (aORs) and presented those diagnosticcategories that each accounted for at least 0.5% of the total ED cohort as a figure (a complete listingof data for all diagnostic categories is shown in eTable 1 in the Supplement). Finally, we used thesemodels to calculate the adjusted proportion of visits with imaging for each race/ethnicity group. Weapplied the adjusted proportion of imaging in non-Hispanic White patients to the number of visits bynon-Hispanic Black and Hispanic patients. We then calculated the difference in the number of visitswith imaging when compared with the adjusted proportion with imaging for non-Hispanic Black andHispanic patients, thus establishing how many more or fewer visits would have imaging if imagingrates for visits by non-Hispanic Black and Hispanic patients were the same as those for visits bynon-Hispanic White patients. Missing data were analyzed as a distinct category for relevant variables.All hypothesis testing was 2-sided, with statistical significance defined as P < .05. We used SAS,version 9.4 (SAS Institute, Inc) for all analyses.

Results

Characteristics of the Study CohortWe included a total of 13 087 522 ED visits by 6 230 911 patients (mean [SD] age, 5.8 [5.2] years;52.7% of visits by male patients and 47.3% by female patients) to the 44 pediatric EDs during the4-year study period. There were 4 496 961 visits (34.4%) by non-Hispanic White, 3 339 043 (25.5%)by non-Hispanic Black, and 3 722 613 (28.4%) by Hispanic patients in the study cohort and 1 528 905(11.7%) by patients in the other category (Table 1). Insurance status varied across race/ethnicitygroups, with 44.2% of visits by non-Hispanic White patients, 79.5% of visits by non-Hispanic Blackpatients, 81.6% of visits by Hispanic patients, and 63.4% of visits by patients of other races andethnicities covered by public insurance (P < .001). A higher proportion of non-Hispanic Whitepatients were hospitalized (14.3%) compared with non-Hispanic Black (9.4%), Hispanic (8.2%), andother (10.7%) patients (P < .001).

Diagnostic Imaging RatesA total of 3 689 163 (28.2%) of the 13 087 522 ED visits included 1 or more imaging studies (Table 1).Of these visits with imaging, 79.9% included radiography, 19.6% included ultrasonography, 10.6%included CT, and 2.4% included MRI. More than 1 imaging modality was performed in 339 403 visits(9.2%). Imaging was performed in 33.5% of visits by non-Hispanic White children, compared with24.1% of visits by non-Hispanic Black children (OR, 0.60; 95% CI, 0.60-0.60) and 26.1% of visits byHispanic children (OR, 0.66; 95% CI, 0.66-0.67) (Table 2).

Adjusting for relevant confounders, visits by non-Hispanic Black (aOR, 0.82; 95% CI, 0.82-0.83)and Hispanic (aOR, 0.87; 95% CI, 0.87-0.87) patients were less likely than those by non-HispanicWhite patients to include any imaging (Table 2). These patterns of less imaging use for non-HispanicBlack and Hispanic patients were consistent across individual imaging modalities and persisted whenstratified by insurance types (Table 2). Limiting the analysis to the 11 506 168 visits among childrendischarged from the ED, visits by non-Hispanic Black (aOR, 0.79; 95% CI, 0.79-0.80) and Hispanic(aOR, 0.84; 95% CI, 0.84-0.85) children remained less likely to include imaging compared with visitsby non-Hispanic White children (eTable 2 in the Supplement).

Imaging Across Diagnostic Groups Comparing Visits by Non-Hispanic White WithNon-Hispanic Black PatientsImaging was less likely to be performed during ED visits by non-Hispanic Black patients for 15 of the26 diagnostic categories (57.7%) (Figure and eTable 3 in the Supplement). For 4 diagnosticcategories (skin and subcutaneous conditions [aOR, 1.02; 95% CI, 1.01-1.04], blood andimmunological conditions [aOR, 1.08; 95% CI, 1.04-1.12], mental health conditions [aOR, 1.12; 95% CI,1.07-1.18], and hepatobiliary and pancreatic conditions [aOR, 1.14; 95% CI, 1.01-1.28]), imaging was







Table 1. Demographics of Visits to 44 US Children’s Hospitals, by Race and Ethnicity, 2016-2019a

Characteristic

Patient group, No. (%) of visits

All(n = 13 087 522[100])

Non-Hispanic White(n = 4 496 961[34.4])

Non-Hispanic Black(n = 3 339 043[25.5])

Hispanic(n = 3 722 613[28.4])

Other(n = 1 528 905[11.7])b

Imaging

Anyc 3 689 163 (28.2) 1 506 178 (33.5) 804 515 (24.1) 970 447 (26.1) 408 023 (26.7)

Radiography 2 946 226 (22.6) 1 178 071 (26.2) 682 166 (20.4) 760 800 (20.4) 325 189 (21.3)

CT 391 519 (3.0) 184 549 (4.1) 81 027 (2.4) 86 856 (2.3) 39 087 (2.6)

Ultrasonography 721 986 (5.5) 306 372 (6.8) 112 230 (3.4) 219 014 (5.9) 84 370 (5.5)

MRI 87 967 (0.7) 45 013 (1.0) 14 862 (0.4) 18 356 (0.5) 9736 (0.6)

Patient demographics

Age, y

<1 2 095 046 (16.0) 682 836 (15.2) 535 301 (16.0) 596 037 (16.0) 280 872 (18.4)

1-4 4 568 363 (34.9) 1 492 008 (33.2) 1 171 432 (35.1) 1 321 600 (35.5) 583 323 (38.2)

5-12 4 359 681 (33.3) 1 507 180 (33.5) 1 099 042 (32.9) 1 279 046 (34.4) 474 413 (31.0)

13-17 2 064 432 (15.8) 814 937 (18.1) 533 268 (16.0) 525 930 (14.1) 190 297 (12.4)

Male 6 892 618 (52.7) 2 363 545 (52.6) 1 736 555 (52.0) 1 969 724 (52.9) 822 794 (53.8)

Insurance

Public 8 434 049 (66.0) 1 959 040 (44.2) 2 632 413 (79.5) 2 888 826 (81.6) 953 770 (63.4)

Private 3 639 416 (28.5) 2 256 483 (50.9) 479 245 (14.5) 451 044 (12.7) 452 644 (30.1)

Otherd 713 071 (5.6) 215 231 (4.9) 199 869 (6.0) 200 445 (5.7) 97 526 (6.5)

Weekend (vs weekday) 3 773 991 (28.8) 1 356 764 (30.2) 901 966 (27.0) 1 058 157 (28.4) 457 104 (29.9)

ED arrival time

8:00 AM to 3:59 PM 4 908 323 (37.6) 1 666 560 (37.1) 1 332 693 (39.9) 1 357 742 (36.5) 551 328 (36.7)

4:00 to 11:59 PM 6 384 107 (48.9) 2 291 137 (50.9) 1 541 857 (46.2) 1 811 214 (48.7) 739 899 (49.3)

12:00 to 7:59 AM 1 760 130 (13.5) 533 564 (11.9) 462 433 (13.8) 553 299 (14.9) 210 834 (14.0)

Median household income

<25th quartile 2 992 123 (22.9) 466 647 (10.4) 1 271 364 (38.1) 969 112 (26.0) 285 000 (18.6)

25th-50th quartile 2 715 101 (20.7) 777 185 (17.3) 785 451 (23.5) 867 655 (23.3) 284 810 (18.6)

51st-75th quartile 3 264 351 (24.9) 1 200 560 (26.7) 663 973 (19.9) 1 029 831 (27.7) 369 987 (24.2)

>75th quartile 3 873 720 (29.6) 1 957 533 (43.5) 583 059 (17.5) 785 804 (21.1) 547 324 (35.8)

Missing 242 227 (1.9) 95 036 (2.1) 35 196 (1.1) 70 211 (1.9) 41 784 (2.7)

Distance from hospital, miles

<5 3 436 032 (26.4) 734 924 (16.4) 1 330 054 (39.9) 931 248 (25.1) 439 806 (29.1)

5-10 3 705 634 (28.4) 960 133 (21.4) 1 118 592 (33.5) 1 145 697 (30.9) 481 212 (31.8)

10-20 3 133 697 (24.0) 1 264 780 (28.2) 574 626 (17.2) 940 375 (25.4) 353 916 (23.4)

>20 2 761 265 (21.2) 1 524 896 (34.0) 311 027 (9.3) 686 938 (18.5) 238 404 (15.8)

Clinical characteristics

Complex chronic conditions 865 089 (6.6) 350 682 (7.8) 215 884 (6.5) 202 190 (5.4) 96 333 (6.3)

3-d ED revisit 144 659 (1.1) 55 387 (1.2) 32 004 (1.0) 40 476 (1.1) 16 792 (1.1)

Hospital admission 1 428 454 (10.9) 642 913 (14.3) 315 129 (9.4) 306 930 (8.2) 163 482 (10.7)

Intensive care unit admission 152 900 (1.2) 65 258 (1.5) 37 553 (1.1) 31 415 (0.8) 18 674 (1.2)

Major diagnostic category

Alcohol/drug use and induced mental disorders 10 009 (0.1) 4513 (0.1) 1886 (0.1) 2504 (0.1) 1106 (0.1)

Blood and immunological conditions 138 719 (1.1) 38 208 (0.8) 57 925 (1.7) 28 565 (0.8) 14 021 (0.9)

Burns 38 432 (0.3) 13 438 (0.3) 11 556 (0.3) 8081 (0.2) 5357 (0.4)

Circulatory conditions 240 325 (1.8) 89 750 (2.0) 62 528 (1.9) 63 771 (1.7) 24 276 (1.6)

Digestive conditions 1 793 337 (13.7) 627 339 (14.0) 371 817 (11.1) 581 599 (15.6) 212 582 (13.9)

Ear, nose, mouth, and throat conditions 3 252 892 (24.9) 1 016 130 (22.6) 857 565 (25.7) 989 718 (26.6) 389 479 (25.5)

Endocrine and metabolic conditions 171 514 (1.3) 79 310 (1.8) 36 585 (1.1) 37 019 (1.0) 18 600 (1.2)

(continued)




Table 2. Bivariable and Multivariable Association of Race and Ethnicity With Any Imaging by Insurance Types

Imaging type

For imaging, OR (95% CI)

Unadjusted Adjusteda Adjustedb Adjustedc

Any imaging

Non-Hispanic White 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]

Non-Hispanic Black 0.60 (0.60-0.60) 0.82 (0.82-0.83) 0.81 (0.81-0.82) 0.82 (0.82-0.83)

Hispanic 0.66 (0.66-0.67) 0.87 (0.87-0.87) 0.87 (0.86-0.88) 0.87 (0.87-0.88)

Radiography



Hispanic 0.72 (0.72-0.72) 0.91 (0.91-0.92) 0.92 (0.91-0.93) 0.91 (0.90-0.91)

CT



Hispanic 0.56 (0.56-0.57) 0.86 (0.85-0.87) 0.89 (0.87-0.91) 0.87 (0.85-0.88)

Ultrasonography



Hispanic 0.69 (0.68-0.69) 0.86 (0.85-0.89) 0.86 (0.85-0.87) 0.88 (0.87-0.89)

MRI



Hispanic 0.43 (0.42-0.44) 0.85 (0.83-0.87) 0.84 (0.80-0.87) 0.89 (0.86-0.92)

Abbreviations: CT, computed tomography; MRI,magnetic resonance imaging; OR, odds ratio.a Adjusted for age, sex, weekend presentation, hour of

presentation, insurance, hospital admission,intensive care unit admission, hospital site, complexchronic conditions, All Patient Refined–DiagnosisRelated Group category, year, distance from hospital,and 3-day revisit.

b Visits with public insurance adjusted for all variablesincluded in the adjusted model for all visits, exceptfor insurance.

c Visits with private insurance adjusted for all variablesincluded in the adjusted model for all visits exceptfor insurance.

Table 1. Demographics of Visits to 44 US Children’s Hospitals, by Race and Ethnicity, 2016-2019a (continued)

Characteristic

Patient group, No. (%) of visits

All(n = 13 087 522[100])

Non-Hispanic White(n = 4 496 961[34.4])

Non-Hispanic Black(n = 3 339 043[25.5])

Hispanic(n = 3 722 613[28.4])

Other(n = 1 528 905[11.7])b

Eye conditions 331 687 (2.5) 100 806 (2.2) 106 040 (3.2) 87 312 (2.3) 37 529 (2.5)

Female reproductive conditions 65 986 (0.5) 21 401 (0.5) 20 546 (0.6) 17 572 (0.5) 6467 (0.4)

Hepatobiliary and pancreatic conditions 20 440 (0.2) 8125 (0.2) 2852 (0.1) 6983 (0.2) 2480 (0.2)

Human immunodeficiency virus infections 135 (0.001) 16 (0.0004) 90 (0.003) 17 (0.0005) 12 (0.001)

Infectious diseases 1 129 921 (8.6) 332 616 (7.4) 270 248 (8.1) 380 353 (10.2) 146 704 (9.6)

Kidney and urinary conditions 233 346 (1.8) 86 052 (1.9) 43 535 (1.3) 77 254 (2.1) 26 505 (1.7)

Lymphatic, hematopoietic, and other malignancies 11 566 (0.1) 5255 (0.1) 1095 (0.03) 3433 (0.1) 1783 (0.1)

Male reproductive conditions 80 518 (0.6) 29 521 (0.7) 12 716 (0.4) 28 334 (0.8) 9947 (0.7)

Mental health conditions 286 370 (2.2) 141 852 (3.2) 64 840 (1.9) 49 515 (1.3) 30 163 (2.0)

Multiple significant trauma 5161 (0.04) 2572 (0.1) 1186 (0.03) 865 (0.02) 538 (0.04)

Musculoskeletal conditions 1 168 049 (8.9) 483 497 (10.8) 254 183 (7.6) 303 827 (8.2) 126 542 (8.3)

Neonatal conditions 60 363 (0.5) 22 805 (0.5) 11 051 (0.3) 16 196 (0.4) 10 311 (0.7)

Nervous system conditions 581 177 (4.4) 254 540 (5.7) 132 221 (4.0) 133 553 (3.6) 60 863 (4.0)

Poisonings and injuries 279 821 (2.1) 108 261 (2.4) 79 934 (2.4) 59 152 (1.6) 32 474 (2.1)

Pregnancy and childbirth 4991 (0.04) 917 (0.02) 2320 (0.1) 1276 (0.03) 478 (0.03)

Rehabilitation and aftercare 376 599 (2.9) 120 644 (2.7) 97 630 (2.9) 108 626 (2.9) 49 699 (3.3)

Respiratory conditions 1 331 834 (10.2) 401 933 (8.9) 428 398 (12.8) 345 412 (9.3) 156 091 (10.2)

Skin and subcutaneous conditions 1 454 109 (11.1) 500 047 (11.1) 405 058 (12.1) 387 693 (10.4) 161 311 (10.6)

Ungroupable 20 221 (0.2) 7413 (0.2) 5238 (0.2) 3983 (0.1) 3587 (0.2)

Abbreviations: CT, computed tomography; ED, emergency department; MRI, magneticresonance imaging.a P < .001 (Rao-Scott χ2 test) for all variables, except year (P = .08).b Includes American Indian (0.2%), Asian (2.5%), Native Hawaiian (0.2%), multiracial

(1.2%), other race (5.5%), and missing (2.0%).

c Indicates number of visits with at least 1 of the 4 imaging modalities performed; sum ofeach of the 4 imaging modalities is greater than the number of any imaging studiesbecause each visit could include more than 1 imaging modality.

d Includes self-pay (4.5%), charity (0.05%), hospital did not bill (0.003%), andother (0.9%).




Figure. Adjusted Odds of Any Imaging for Visits by Non-Hispanic Black and Hispanic Patients Compared With Non-Hispanic White Patients, by Diagnostic Group

0.5 1.51.0Adjusted odds ratio (95% CI)

P valueFavors imaging in Non-Hispanic White children

Favors imaging inNon-White childrenMDC

Female reproductive conditions

Adjusted oddsratio (95% CI)

Eye conditions

Non-Hispanic Black 0.52 (0.49-0.56)Hispanic 0.87 (0.81-0.93)

Male reproductive conditions

.002<.001

<.001<.001

<.001<.001

<.001<.001

<.001<.001

<.001<.001

<.001

<.001<.001

<.001<.001

<.001<.001

<.001<.001

<.001

<.001

<.001

<.001<.001

<.001

<.001

<.001<.001

<.001<.001

.22

.12

.20

.14

.004

.10

Non-Hispanic Black 0.58 (0.55-0.62)

Digestive conditions

Kidney and urinary conditions

Rehabilitation and aftercare

Respiratory conditions

Ear, nose, mouth, and throat conditions

Infectious diseases

Musculoskeletal conditions

Neonatal conditions

Circulatory conditions

Poisonings and injuries

Nervous system conditions

Endocrine and metabolic conditions

Skin and subcutaneous conditions

Blood and immunological conditions

Mental health conditions

Total

Hispanic 0.57 (0.54-0.60)







Hispanic 0.80 (0.79-0.82)











Hispanic 0.98 (0.95-1.01)

Hispanic 0.81 (0.79-0.82)


Diagnostic categories presented are those that each accounted for at least 0.5% of thetotal emergency department cohort. MDC indicates major diagnostic category. Oddsratios are adjusted for age, sex, weekend presentation, hour of presentation, insurance,

hospital admission, intensive care unit admission, hospital site, complex chronicconditions, year, distance from hospital, and 3-day revisit.




more likely to be performed during visits by non-Hispanic Black patients, and for 7 diagnosticcategories there were no differences. The largest differences in odds of imaging comparing visits bynon-Hispanic Black with those by non-Hispanic White patients were for conditions related to thefemale (aOR, 0.52; 95% CI, 0.49-0.56) and male reproductive system (aOR, 0.58; 95% CI,0.55-0.62), eyes (aOR, 0.69; 95% CI, 0.65-0.72), and digestive system (aOR, 0.69; 95% CI,0.69-0.70).

Imaging Across Diagnostic Groups Comparing Visits by Non-Hispanic WhiteWith Hispanic PatientsImaging was less likely to be performed during visits by Hispanic patients compared with those bynon-Hispanic White patients for 13 of the 26 diagnostic categories (50.0%), more likely for 2diagnostic categories (mental health conditions [aOR, 1.32; 95% CI, 1.25-1.39] and lymphatic,hematopoietic, and other malignancies [malignant neoplasms] [aOR, 1.15; 95% CI, 1.01-1.31), andequallt likely for 11 categories (Figure and eTable 3 in the Supplement). The largest imagingdifferences were for conditions related to the male reproductive system (aOR, 0.57; 95% CI,0.54-0.60), eye (aOR, 0.69; 95% CI, 0.65-0.73), and digestive conditions (aOR, 0.78; 95% CI, 0.77-0.78).

Table 3 and eTable 4 in the Supplement show the adjusted differences in the number of visitswith imaging by major diagnostic category and ICD-10-CM codes, respectively, for non-Hispanic Blackand Hispanic patients relative to the expected number of visits with imaging using the adjustedproportion of imaging for non-Hispanic White patients. Overall, if imaging rates among visits bynon-Hispanic Black and Hispanic patients were the same as those for visits by non-Hispanic Whitepatients, there would have been 59 993 more visits by non-Hispanic Black patients with imaging and41 572 more visits by Hispanic patients with imaging. The largest differences were observed for visitsrelated to digestive conditions. Specifically, if the imaging rate for visits by non-Hispanic Blackpatients with digestive conditions was the same as that for visits by non-Hispanic White patients,there would have been 17 909 (4.8%) more visits with imaging among the 371 817 visits bynon-Hispanic Black patients in this diagnostic category; similarly, if the imaging rate for visits byHispanic patients with digestive conditions was the same as that for visits by non-Hispanic Whitepatients, there would have been 15 067 (2.6%) more visits with imaging among the 581 599 visits byHispanic patients with this diagnosis.

Discussion

In this study of more than 13 million visits to 44 pediatric EDs, we observed that visits bynon-Hispanic Black and Hispanic patients were less likely to include radiography, CT, ultrasonography,and MRI compared with those by non-Hispanic White patients. These findings were consistent acrossmost diagnostic groups, persisted when stratified by insurance type, and were even morepronounced on analysis of only visits by nonhospitalized children. Our findings suggest that a child’srace and ethnicity may be independently associated with the decision to perform imaging duringED visits.

The differential use of diagnostic imaging by race/ethnicity may reflect underuse of imaging innon-Hispanic Black and Hispanic children, or alternatively, overuse in non-Hispanic White children.Overuse may expose these children to unnecessary risks associated with imaging.3,4,7 Conversely,underuse may result in misdiagnoses, need for further care, and potentially worse clinicaloutcomes.40-42 Although we were unable to discern underuse from overuse using an administrativedatabase, it is likely that much of the imaging in White children is unnecessary.43 There are manyexamples of imaging overuse among White children, with no differences in clinical outcomes. Forexample, compared with non-White children, White children have higher rates of advanced imagingfor abdominal pain and abdominal trauma9,10,44 and chest radiographs for bronchiolitis,11 asthma,12

and chest pain.45 Similarly, a multicenter study observed that White children with head trauma had






Table 3. Differences in Any Imaging Between Race and Ethnicity Groups by Major Diagnostic Category

Major diagnosticcategorya

Patient group Adjusted differencein No. of visits withimagingbNHW NHB Hispanic

No. of visits

No. ofvisits withimaging

Adjustedproportion ofvisits withimaging, %c No. of visits


Adjustedproportion ofvisits withimaging, %c No. of visits


Adjustedproportion ofvisits withimaging, %c

NHB vsNHW

Hispanicvs NHW

Digestiveconditions

627 339 311 700 42.5 371 817 122 990 37.7 581 599 208 132 39.9 −17 909 −15 067

Respiratoryconditions

401 933 171 252 36.2 428 398 116 737 32.9 345 412 124 055 35.6 −14 039 −1992

Ear, nose, mouth,and throatconditions

1 016 130 129 733 11.2 857 565 78 389 9.9 989 718 92 937 10.1 −10 909 −10 517

Infectiousdiseases

332 616 70 661 17.2 270 248 37 486 15.6 380 353 52 585 15.8 −4246 −5327

Musculoskeletalconditions

483 497 396 072 81.1 254 183 202 481 79.7 303 827 241 225 80.7 −3428 −1135

Rehabilitationand aftercare

120 644 27 645 18.7 97 630 13 611 15.8 108 626 15 851 17.0 −2832 −1855

Kidney andurinary conditions

86 052 33 068 33.4 43 535 11 283 28.9 77 254 21 766 31.7 −1952 −1338

Femalereproductiveconditions

21 401 7214 30.5 20 546 3828 23.7 17 572 5727 29.1 −1402 −245

Eye conditions 100 806 8051 6.1 106 040 4487 5.1 87 312 3875 5.2 −1127 −828

Nervous systemconditions

254 540 89 702 32.7 132 221 38 519 31.9 133 553 40 631 32.5 −1088 −205

Circulatoryconditions

89 750 44 072 49.7 62 528 29 352 48.1 63 771 32 836 49.5 −1041 −175

Male reproductiveconditions

29 521 18 858 56.0 12 716 6024 49.3 28 334 12 394 50.2 −862 −1667

Poisoningsand injuries

108 261 15 336 13.3 79 934 10 130 12.8 59 152 6882 12.9 −430 −272

Endocrine andmetabolicconditions

79 310 22 342 27.8 36 585 9468 27.5 37 019 10 476 27.5 −99 −110

Neonatalconditions

22 805 4545 16.7 11 051 1556 15.9 16 196 1932 14.6 −91 −342

Pregnancy andchildbirth

917 284 28.1 2320 550 26.7 1276 416 28.9 −34 10

Alcohol/drug useand inducedmental disorders

4513 607 13.5 1886 237 13.3 2504 383 14.7 −3 31

HIV infections 16 9 57.7 90 52 56.8 17 9 57.1 −1 0

Multiplesignificant trauma

2572 2406 94.6 1186 1148 94.9 865 834 95.7 4 9

Burns 13 438 673 4.6 11 556 568 4.7 8081 272 4.3 8 −21

Lymphatic,hematopoietic,and othermalignancies

5255 3070 57.2 1095 644 58.7 3433 1947 58.7 17 53

Hepatobiliaryand pancreaticconditions

8125 5675 69.8 2852 2099 71.5 6983 4859 70.5 48 51

Mental healthconditions

141 852 7491 5.5 64 840 3616 5.9 49 515 3679 6.4 237 428

Blood andimmunologicalconditions

38 208 14 678 44.9 57 925 30 561 45.6 28 565 11 023 44.3 397 −173

Skin andsubcutaneousconditions

500 047 117 119 20.7 405 058 76 561 20.9 387 693 73 966 20.5 814 −864

Ungroupable 7413 3915 47.2 5238 2138 46.7 3983 1755 46.7 −25 −21

Abbreviations: NHB, non-Hispanic Black; NHW, non-Hispanic White.a Indicates abbreviated category names (see eTable 1 in the Supplement for full

category names).b Relative to expected number of visits with imaging for NHW patients.

c Adjusted for age, sex, weekend presentation, hour of presentation, insurance, hospitaladmission, intensive care unit admission, hospital site, complex chronic conditions, AllPatient Refined–Diagnosis Related Group category, year, distance from hospital, and 3-day revisit.





higher rates of CT than non-White children,46 even among those at the lowest risk forsubstantial injury.8

There are a number of possible explanations for our findings, including a combination of parent/guardian preferences, clinician biases, and structural factors.47 Higher imaging rates observed innon-Hispanic White patients may, in part, be attributed to greater levels of parental anxiety with anassociated increase in requests for imaging. Such a mechanism has been proposed to be a factordriving the overuse of head imaging in children at low risk of serious traumatic head injury.8 Theremay also be perceived differences in the risk-balance ratio of imaging relative to radiation exposure.A survey of adult patients in the ED reported that White patients preferred a definitive diagnostictest, such as CT, even at the expense of radiation.48 Language barriers may also play a role. Forexample, non–English-speaking patients and their families may be more49 or less24 likely to havetesting performed as part of their ED visit. Physicians’ implicit racial biases are an importantconsideration and have been associated with patient-clinician interactions, treatment decisions,treatment adherence, and patient health outcomes.50 These biases are exacerbated in times ofstress, which is particularly relevant to ED clinicians.51 Structural factors rooted in our health caresystem also likely contributed to differential imaging rates. For example, minority patients are lesslikely than White patients to have a medical home,52 which may influence whether clinicians orderimaging during the ED visit or defer to outpatient management, and some imaging in White childrenmay have been driven by primary care clinician referral.

With more than 1 in every 4 ED visits in this study including an imaging study, clinicians arefrequently performing diagnostic imaging. The goal, undoubtedly, assuming similar clinicalpresentations across racial and ethnic groups, is to enable parity in diagnostic imaging across thesegroups. Adherence to clinical guidelines and other objective scoring tools have the potential toreduce subjectivity, support team-based decision-making, and improve communication andstructurally competent clinical care.47,53-55 Internal quality assurance evaluations to betterunderstand physician-level practices that may be influenced by implicit bias may also narrow thedisparity gap.54,56 In addition, future work is needed to better understand hospital-level disparitiesin imaging delivery. Such evaluations at the hospital and clinician level are needed to enhance thequality of care delivered and health outcomes for all children.

LimitationsThis study has limitations. The PHIS does not include clinical data regarding the indication forimaging, and there may be unmeasured confounders. We were unable to fully account for illnessseverity, given the limited clinical information contained within the PHIS (eg, Emergency SeverityIndex). It is possible that non-Hispanic White children had higher illness acuity, potentially accountingfor higher rates of diagnostic imaging. We attempted to minimize this limitation by restricting theanalysis to nonhospitalized children and observed even larger differences in imaging rates by race/ethnicity. Race and ethnicity of some patients may have been misclassified given the varyingmethods of assigning race across PHIS hospitals. However, prior work evaluating race and ethnicitydata in children in administrative data57 found high accuracy in ethnicity and for White and Blackrace. We were unable to evaluate or control for limited English proficiency because these data are notavailable in the PHIS. Imaging for admitted patients may have been misclassified as having occurredas part of the inpatient stay and not the ED visit (and vice versa); notably, admitted patients were aminority of the patient population. Finally, this study was specific to US children’s hospitals, andtherefore, the findings are not generalizable to other EDs, care settings, or countries.

Conclusions

There are significant racial and ethnic differences in diagnostic imaging rates among children seekingcare in US pediatric EDs. These differences persist across insurance groups and in analyses limitedto discharged children. Further investigation is needed to better understand the factors




underpinning these disparities, with the goal of developing measurable interventions to mitigate thedisparities in ED imaging and allowing for more equitable and improved care.

ARTICLE INFORMATIONAccepted for Publication: November 24, 2020.

Published: January 29, 2021. doi:10.1001/jamanetworkopen.2020.33710

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Marin JR et al.JAMA Network Open.

Corresponding Author: Jennifer R. Marin, MD, MSc, Department of Pediatrics, University of Pittsburgh School ofMedicine, 4401 Penn Ave, Administrative Office Building Ste 2400, Pittsburgh, PA 15224 ([email protected]).

Author Affiliations: Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania(Marin); Department of Radiology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania (Marin);Children’s Hospital Association, Lenexa, Kansas (Rodean, Hall); Division of Emergency Medicine, Department ofPediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School ofMedicine, Chicago, Illinois (Alpern); Section of Pediatric Emergency Medicine, Departments of Pediatrics andEmergency Medicine, Yale School of Medicine, New Haven, Connecticut (Aronson); Division of Emergency andTransport Medicine, Children’s Hospital Los Angeles, Keck School of Medicine of the University of SouthernCalifornia, Los Angeles (Chaudhari); Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario,Canada (Cohen); Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics,Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, Universityof Calgary, Calgary, Alberta, Canada (Freedman); Department of Emergency Medicine, Alberta Children’s Hospital,Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary,Alberta, Canada (Freedman); Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio (Morse);Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston,Massachusetts (Peltz); Department of Emergency Medicine, Massachusetts General Hospital, Boston (Samuels-Kalow); Divisions of Hospital Medicine and Infectious Diseases, Department of Pediatrics, Cincinnati Children’sHospital Medical Center, Cincinnati, Ohio (Shah); Division of Emergency Medicine, Departments of Pediatrics andEmergency Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia(Simon); Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston,Massachusetts (Neuman).

Author Contributions: Dr Marin and Mr Rodean had full access to all the data in the study and take responsibilityfor the integrity of the data and the accuracy of the data analysis.

Concept and design: Marin, Hall, Alpern, Aronson, Chaudhari, Freedman, Morse, Peltz, Samuels-Kalow,Shah, Neuman.

Acquisition, analysis, or interpretation of data: Marin, Rodean, Hall, Aronson, Chaudhari, Cohen, Freedman, Peltz,Shah, Simon, Neuman.

Drafting of the manuscript: Marin, Chaudhari, Morse, Peltz, Simon, Neuman.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Rodean, Chaudhari, Peltz.

Administrative, technical, or material support: Chaudhari, Freedman, Simon, Neuman.

Supervision: Marin, Chaudhari, Neuman.

Conflict of Interest Disclosures: Dr Aronson reported receiving a grant from the Agency for Healthcare Researchand Quality during the conduct of the study. Dr Freedman reported receiving grant support from the AlbertaChildren’s Hospital Foundation Professorship in Child Health and Wellness. Dr Samuels-Kalow reported receiving agrant from the National Center for Advancing Translational Sciences, National Institutes of Health, and the HarvardCatalyst and Harvard Clinical and Translational Science Center. Dr Simon reported receiving a ConcussionManagement Grant from the Centers for Disease Control and Prevention, a Pediatric Emergency Care AppliedResearch Network grant from the Health Resources and Services Administration, and a grant from the GeorgiaClinical and Translational Science Alliance, National Center for Advancing Translational Sciences. No otherdisclosures were reported.





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https://dx.doi.org/10.1542/hpeds.2018-0223


https://dx.doi.org/10.1016/j.jpeds.2018.12.029


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SUPPLEMENT.eTable 1. Principal ICD-10-CM Codes Associated With the Major Diagnostic CategorieseTable 2. Multivariable Association of Race and Ethnicity With Any Imaging for ED Visits Resulting in DischargeeTable 3. Adjusted Odds of Any Imaging for Visits by Non-Hispanic Black and Hispanic Patients Compared WithNon-Hispanic White Patients, by Diagnostic GroupeTable 4. Differences in Any Imaging Between Race and Ethnicity Groups, by Top 10 ICD-10-CM Codes With theHighest Volumes of Diagnostic Imaging







https://dx.doi.org/10.1016/S0033-3549(04)50253-4

https://dx.doi.org/10.2214/AJR.09.3847

https://dx.doi.org/10.1542/peds.103.6.1253

https://dx.doi.org/10.2105/AJPH.2015.302903









https://dx.doi.org/10.1186/1472-6963-10-316

https://dx.doi.org/10.1186/1472-6963-10-316

racial and ethnic differences in emergency department

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