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Neuroimaging-use trends in nonacute pediatric headache before and after clinical practice parameters
William D Graf1, Husam R Kayyali, John J Alexander
1Sections of aNeurology, Children's Mercy Hospitals and Clinics, Kansas City, Missouri 64108, USA. wdgraf@cmh.edu
Insights
Neuroimaging use for pediatric headache remained stable after guidelines were published. Primary care providers increasingly ordered these tests, suggesting evidence-based medicine may curb overuse.
Area of Science:
- Pediatric Neurology
- Diagnostic Imaging
- Evidence-Based Medicine
Background:
- Clinical practice guidelines aim to standardize care and optimize diagnostic testing.
- Neuroimaging is frequently used in evaluating pediatric headache, raising concerns about overuse and cost-effectiveness.
Purpose of the Study:
- To assess trends in diagnostic neuroimaging use for nonacute pediatric headache.
- To evaluate changes before and after the publication of clinical practice guidelines.
Main Methods:
- Retrospective analysis of 725 children (3-18 years) with nonacute headache and normal neurologic exams.
- Data collected from 1992 to 2004, excluding patients with indications for neuroimaging.
- Recorded neuroimaging request origin and significant findings.
Main Results:
- Overall neuroimaging rate was 45% and remained stable (41%-47%) over 13 years.
- Primary care providers ordered the majority of neuroimaging studies.
- The proportion of neuroimaging ordered by primary care providers significantly increased from 1992 to 2004.
Conclusions:
- Neuroimaging use for nonacute pediatric headache referrals to neurology clinics was stable.
- Increasing neuroimaging orders by primary care providers were observed.
- Evidence-based medicine may be limiting overuse, but physician and consumer perceptions warrant further study.
Objectives:
The objective of this study was to determine trends in diagnostic neuroimaging-use rates in nonacute pediatric headache before and after publication of clinical practice guidelines.
Methods:
Retrospective, cross-sectional analysis was conducted of neuroimaging rates for 725 children and adolescents who were aged 3 to 18 years with nonacute headache and normal neurologic examination and were evaluated in a single pediatric neurology clinic during study years 1992, 1996, 2000, and 2004. Following recommendations of current practice parameters, patients with conditions that justify consideration for neuroimaging (eg, progressive headache, abnormal neurologic examination) were excluded from this analysis. We recorded the origin of any neuroimaging request at the time of the clinic visit and any abnormal neuroimaging findings that led to major clinical consequences.
Results:
Overall, the mean rate of neuroimaging for patients with nonacute headache was 45%. Use rates remained steady during the 13-year study period (range: 41%-47%). The majority of neuroimaging studies were ordered originally by primary care providers. The proportion of neuroimaging studies that were ordered by primary care providers increased significantly from 1992 to 2004.
Conclusions:
In the evaluation of patients who had nonacute pediatric headache and were referred to a child neurology clinic, neuroimaging-use rates remained stable during the past decade. An increasing proportion of neuroimaging studies are ordered by primary care providers. The influence of evidence-based medicine on medical decision-making may be partly responsible for curbing increases in neuroimaging overuse. The perceived value of neuroimaging by physicians and consumers deserves ongoing study.
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