title: Variability in the emergency department use of discretionary radiographs in children with common respiratory conditions: the mixed effect of access to pediatrician care.
abstract: OBJECTIVE
  The objective of this study was to investigate whether different staffing models are associated with variation in radiograph use for children seen for bronchiolitis, croup, and asthma and discharged home from emergency departments (EDs) in Ontario.
  
  
  METHODS
  We surveyed all Ontario EDs regarding physician staffing models and use of clinical protocols. We used a population-based ED database to determine radiograph rates and patient characteristics. Regression techniques that controlled for patient factors and clustering within EDs were applied.
  
  
  RESULTS
  From April 2004 to March 2006, 5,186, 10,408, and 35,150 children were discharged home from an ED with bronchiolitis, croup, and asthma, respectively. Radiograph rates were 42.7% for bronchiolitis, 10.1% for croup, and 25.9% for asthma. Over 50% of children were treated in EDs with nonpediatric front-line care but with consultant pediatricians available. Compared to children in these settings, those seen in EDs with front-line pediatric staff were less likely to have radiographs for all three conditions (adjusted odds ratios [ORs] 0.47 [95% CI 0.24-0.95], 0.47 [95% CI 0.27-0.82], 0.13 [95% CI 0.02-0.66] for bronchiolitis, croup, and asthma, respectively). Children in community hospitals with pediatricians were significantly more likely to have a radiograph if seen by a consultant pediatrician (OR 1.40, 95% CI 1.20-1.63 [bronchiolitis]; OR 2.76, 95% CI 2.16-3.53 [croup]; and OR 1.97, 95% CI 1.64-2.36 [asthma]). We found no association between clinical protocol use and radiograph rates.
  
  
  CONCLUSIONS
  High rates of discretionary radiograph use exist for common respiratory problems of children seen across ED settings. Quality improvement efforts should be focused in this area, and radiograph use in EDs staffed by front-line pediatrics-trained staff could serve as an initial benchmark target for other institutions.
authors.affiliation: Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, ON, Canada. astrid.guttmann@ices.on.ca
authors.forename: Astrid
authors.initials: A
authors.lastname: Guttmann
authors.forename: Michael
authors.initials: M
authors.lastname: Weinstein
authors.forename: Peter C
authors.initials: PC
authors.lastname: Austin
authors.forename: Azim
authors.initials: A
authors.lastname: Bhamani
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Anderson
mesh_terms: D001249:Asthma / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000503:physiopathology; D001988:Bronchiolitis / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000503:physiopathology; D016009:Chi-Square Distribution; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003440:Croup / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000503:physiopathology; D016208:Databases, Factual; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D016017:Odds Ratio; D009864:Ontario; D010351:Patient Discharge / Q000706:statistics & numerical data*; D010372:Pediatrics / Q000592:standards / Q000639:trends; D010818:Practice Patterns, Physicians'; D013902:Radiography, Thoracic / Q000706:statistics & numerical data*; D012140:Respiratory Tract Diseases / Q000000981:diagnostic imaging* / Q000453:epidemiology* / Q000628:therapy; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index