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      Low-Value Diagnostic Imaging Use in the Pediatric Emergency Department in the United States and Canada

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          Abstract

          Are there differences in the use of diagnostic imaging between pediatric emergency departments located in the United States and Canada? In this cohort study, overall and low-value diagnostic imaging use rates were lower in pediatric emergency departments in Ontario, Canada, than those in the United States. No differences in post–emergency department adverse outcomes were observed. There may be opportunities to safely reduce imaging rates in pediatric emergency departments in the United States. This cohort study combines data from 4 pediatric emergency departments in Ontario, Canada, and 26 pediatric emergency departments in the United States to compare overall and low-value use of diagnostic imaging across pediatric emergency care. Diagnostic imaging overuse in children evaluated in emergency departments (EDs) is a potential target for reducing low-value care. Variation in practice patterns across Canada and the United States stemming from organization of care, payment structures, and medicolegal environments may lead to differences in imaging overuse between countries. To compare overall and low-value use of diagnostic imaging across pediatric ED visits in Ontario, Canada, and the United States. This study used administrative health databases from 4 pediatric EDs in Ontario and 26 in the United States in calendar years 2006 through 2016. Individuals 18 years and younger who were discharged from the ED, including after visits for diagnoses in which imaging is not routinely recommended (eg, asthma, bronchiolitis, abdominal pain, constipation, concussion, febrile convulsion, seizure, and headache) were included. Data analysis occurred from April 2018 to October 2018. Diagnostic imaging use. Overall and condition-specific low-value imaging use. Three-day and 7-day rates of hospital admission and those admissions resulting in intensive care, surgery, or in-hospital mortality were assessed as balancing measures. A total of 1 783 752 visits in Ontario and 21 807 332 visits in the United States were analyzed. Compared with visits in the United States, those in Canada had lower overall use of head computed tomography (Canada, 22 942 [1.3%] vs the United States, 753 270 [3.5%]; P  < .001), abdomen computed tomography (5626 [0.3%] vs 211 018 [1.0%]; P  < .001), chest radiographic imaging (208 843 [11.7%] vs 3 408 540 [15.6%]; P  < .001), and abdominal radiographic imaging (77 147 [4.3%] vs 3 607 141 [16.5%]; P  < .001). Low-value imaging use was lower in Canada than the United States for multiple indications, including abdominal radiographic images for constipation (absolute difference, 23.7% [95% CI, 23.2%-24.3%]) and abdominal pain (20.6% [95% CI, 20.3%-21.0%]) and head computed tomographic scans for concussion (22.9% [95% CI, 22.3%-23.4%]). Abdominal computed tomographic use for constipation and abdominal pain, although low overall, were approximately 10-fold higher in the United States (0.1% [95% CI, 0.1%-0.2%] vs 1.2% [95% CI, 1.2%-1.2%]) and abdominal pain (0.8% [95% CI, 0.7%-0.9%] vs 7.0% [95% CI, 6.9%-7.1%]). Rates of 3-day and 7-day post-ED adverse outcomes were similar. Low-value imaging rates were lower in pediatric EDs in Ontario compared with the United States, particularly those involving ionizing radiation. Lower use of imaging in Canada was not associated with higher rates of adverse outcomes, suggesting that usage may be safely reduced in the United States.

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          Most cited references 28

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          Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation

          Background The pediatric complex chronic conditions (CCC) classification system, developed in 2000, requires revision to accommodate the International Classification of Disease 10th Revision (ICD-10). To update the CCC classification system, we incorporated ICD-9 diagnostic codes that had been either omitted or incorrectly specified in the original system, and then translated between ICD-9 and ICD-10 using General Equivalence Mappings (GEMs). We further reviewed all codes in the ICD-9 and ICD-10 systems to include both diagnostic and procedural codes indicative of technology dependence or organ transplantation. We applied the provisional CCC version 2 (v2) system to death certificate information and 2 databases of health utilization, reviewed the resulting CCC classifications, and corrected any misclassifications. Finally, we evaluated performance of the CCC v2 system by assessing: 1) the stability of the system between ICD-9 and ICD-10 codes using data which included both ICD-9 codes and ICD-10 codes; 2) the year-to-year stability before and after ICD-10 implementation; and 3) the proportions of patients classified as having a CCC in both the v1 and v2 systems. Results The CCC v2 classification system consists of diagnostic and procedural codes that incorporate a new neonatal CCC category as well as domains of complexity arising from technology dependence or organ transplantation. CCC v2 demonstrated close comparability between ICD-9 and ICD-10 and did not detect significant discontinuity in temporal trends of death in the United States. Compared to the original system, CCC v2 resulted in a 1.0% absolute (10% relative) increase in the number of patients identified as having a CCC in national hospitalization dataset, and a 0.4% absolute (24% relative) increase in a national emergency department dataset. Conclusions The updated CCC v2 system is comprehensive and multidimensional, and provides a necessary update to accommodate widespread implementation of ICD-10.
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            Costs of health care administration in the United States and Canada.

            A decade ago, the administrative costs of health care in the United States greatly exceeded those in Canada. We investigated whether the ascendancy of computerization, managed care, and the adoption of more businesslike approaches to health care have decreased administrative costs. For the United States and Canada, we calculated the administrative costs of health insurers, employers' health benefit programs, hospitals, practitioners' offices, nursing homes, and home care agencies in 1999. We analyzed published data, surveys of physicians, employment data, and detailed cost reports filed by hospitals, nursing homes, and home care agencies. In calculating the administrative share of health care spending, we excluded retail pharmacy sales and a few other categories for which data on administrative costs were unavailable. We used census surveys to explore trends over time in administrative employment in health care settings. Costs are reported in U.S. dollars. In 1999, health administration costs totaled at least 294.3 billion dollars in the United States, or 1,059 dollars per capita, as compared with 307 dollars per capita in Canada. After exclusions, administration accounted for 31.0 percent of health care expenditures in the United States and 16.7 percent of health care expenditures in Canada. Canada's national health insurance program had overhead of 1.3 percent; the overhead among Canada's private insurers was higher than that in the United States (13.2 percent vs. 11.7 percent). Providers' administrative costs were far lower in Canada. Between 1969 and 1999, the share of the U.S. health care labor force accounted for by administrative workers grew from 18.2 percent to 27.3 percent. In Canada, it grew from 16.0 percent in 1971 to 19.1 percent in 1996. (Both nations' figures exclude insurance-industry personnel.) The gap between U.S. and Canadian spending on health care administration has grown to 752 dollars per capita. A large sum might be saved in the United States if administrative costs could be trimmed by implementing a Canadian-style health care system. Copyright 2003 Massachusetts Medical Society
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              Neurodiagnostic evaluation of the child with a simple febrile seizure.

               ,   (2011)
              To formulate evidence-based recommendations for health care professionals about the diagnosis and evaluation of a simple febrile seizure in infants and young children 6 through 60 months of age and to revise the practice guideline published by the American Academy of Pediatrics (AAP) in 1996. This review included search and analysis of the medical literature published since the last version of the guideline. Physicians with expertise and experience in the fields of neurology and epilepsy, pediatrics, epidemiology, and research methodologies constituted a subcommittee of the AAP Steering Committee on Quality Improvement and Management. The steering committee and other groups within the AAP and organizations outside the AAP reviewed the guideline. The subcommittee member who reviewed the literature for the 1996 AAP practice guidelines searched for articles published since the last guideline through 2009, supplemented by articles submitted by other committee members. Results from the literature search were provided to the subcommittee members for review. Interventions of direct interest included lumbar puncture, electroencephalography, blood studies, and neuroimaging. Multiple issues were raised and discussed iteratively until consensus was reached about recommendations. The strength of evidence supporting each recommendation and the strength of the recommendation were assessed by the committee member most experienced in informatics and epidemiology and graded according to AAP policy. Clinicians evaluating infants or young children after a simple febrile seizure should direct their attention toward identifying the cause of the child's fever. Meningitis should be considered in the differential diagnosis for any febrile child, and lumbar puncture should be performed if there are clinical signs or symptoms of concern. For any infant between 6 and 12 months of age who presents with a seizure and fever, a lumbar puncture is an option when the child is considered deficient in Haemophilus influenzae type b (Hib) or Streptococcus pneumoniae immunizations (ie, has not received scheduled immunizations as recommended), or when immunization status cannot be determined, because of an increased risk of bacterial meningitis. A lumbar puncture is an option for children who are pretreated with antibiotics. In general, a simple febrile seizure does not usually require further evaluation, specifically electroencephalography, blood studies, or neuroimaging.
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                Author and article information

                Journal
                JAMA Pediatrics
                JAMA Pediatr
                American Medical Association (AMA)
                2168-6203
                August 01 2019
                August 05 2019
                : 173
                : 8
                : e191439
                Affiliations
                [1 ]Division of Pediatric Medicine, Department of Pediatrics and Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
                [2 ]Department of Pediatrics, Institute of Health Policy, Management & Evaluation, The University of Toronto, Toronto, Ontario, Canada
                [3 ]ICES, Toronto, Ontario, Canada
                [4 ]Children’s Hospital Association, Lenexa, Kansas
                [5 ]Section of Pediatric Emergency Medicine, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
                [6 ]Section of Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
                [7 ]Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
                [8 ]Division of Emergency Medicine, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
                [9 ]Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
                [10 ]Children’s Healthcare of Atlanta, Atlanta, Georgia
                [11 ]Division of Pediatric Emergency Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
                [12 ]Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
                [13 ]Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
                [14 ]Children’s Health System of Texas, Dallas
                [15 ]Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
                [16 ]Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
                [17 ]Yale School of Medicine, New Haven, Connecticut
                [18 ]Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, Boston, Massachusetts
                Article
                10.1001/jamapediatrics.2019.1439
                6547126
                31157877
                © 2019

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