Emergency Provider Use of Plain Radiographs in the Evaluation of Pediatric Constipation

Thesis (Master's)--University of Washington, 2016-06

Background: Abdominal pain is the fourth most common pediatric outpatient complaint, with over half eventually being diagnosed with constipation. X-ray use in the evaluation of constipation is variable: 4% in outpatient/clinic settings but over 70% of children with constipation evaluated in an emergency department. X-rays use increases misdiagnosis rate, remains costly, and involves radiation exposure. Objectives: To assess the use of plain radiographs by Pediatric Emergency Medicine (PEM) providers in the routine diagnostic evaluation and management of pediatric constipation Methods: A cross-sectional, quarterly survey of pediatric emergency medicine providers was performed. Survey participants were subscribers to the American Academy of Pediatrics Section On Emergency Medicine (AAP-SOEM) list-serv. Participants were presented a case of pediatric constipation meeting Rome-III clinical criteria to assess both diagnostic and therapeutic approaches. Participants were asked to categorize frequency of x-ray use, reasons for obtaining, estimated diagnostic utility, and elements of institutional standard diagnostic approach to constipation, if applicable. Descriptive statistical analyses were performed. Results: 305 of 1272 eligible list-serv members (24%) responded, with 272 complete surveys. 86% were PEM-boarded with over half more that 10 years since completing fellowship. 99% elected to treat for constipation a child meeting Rome-III clinical criteria; one-third (31%) would obtain plain radiographs for this same child. Plain radiographs were viewed as somewhat (59%) or minimally (29%) value-added in the clinical evaluation of suspected pediatric constipation. The most common reasons for obtain plain radiographs were: obtaining family buy-in (44%) and ruling out other diagnosis (19%). Frequency of x-ray use varied across geographic regions and with participant and hospital characteristics. Conclusion: This survey suggests that many physicians are obtaining radiographs to convince families of the diagnosis of constipation. This is not a viable management plan given the risks of radiation as well as financial costs to the family and medical system. There remains room for improvement as we attempt to reduce use of ionizing radiation in the evaluation of common pediatric illnesses.