Related Experiment Video
Updated: Sep 26, 2025
Making MR Imaging Child's Play - Pediatric Neuroimaging Protocol, Guidelines and Procedure
Published on: July 30, 2009
Practice Variation in Use of Neuroimaging Among Infants With Concern for Abuse Treated in Children's Hospitals
M Katherine Henry1,2,3,4, Samantha Schilling5, Justine Shults3,6
1Safe Place: Center for Child Protection and Health, Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
Insights
Pediatric hospitals show significant variation in neuroimaging practices for infants with fractures concerning for abuse. Disparities linked to insurance type highlight needs for improved quality, safety, and equity in care.
Area of Science:
- Pediatric medicine
- Medical imaging
- Child abuse evaluation
Background:
- Infants with fractures suggestive of abuse are at high risk for occult head injuries.
- Variations in neuroimaging practices may indicate areas for quality and safety improvements.
Purpose of the Study:
- Quantify neuroimaging practice variation among children's hospitals for infants with fractures evaluated for abuse.
- Identify factors associated with neuroimaging use, including age and insurance type.
Main Methods:
- Cross-sectional study of 2585 infants (<12 months) with femur or humerus fractures at 44 US children's hospitals (2016-2020).
- Multivariable logistic regression analyzed factors associated with neuroimaging (CT or MRI) use.
- Marginal standardization reported adjusted percentages of neuroimaging by hospital and payer type.
Main Results:
- 59.9% of eligible infants underwent neuroimaging.
- Younger age, male sex, public insurance, and combined femur/humerus fractures were associated with increased neuroimaging.
- Significant hospital variation in neuroimaging use (37.4% to 83.6%) was observed; race/ethnicity was not associated.
Conclusions:
- Children's hospitals exhibit considerable variation in neuroimaging for infants with suspected abuse-related fractures.
- Disparities in neuroimaging rates based on insurance type suggest opportunities for quality, safety, and equity enhancements.
Importance:
Infants who appear neurologically well and have fractures concerning for abuse are at increased risk for clinically occult head injuries. Evidence of excess variation in neuroimaging practices when abuse is suspected may indicate opportunity for quality and safety improvement.
Objective:
To quantify neuroimaging practice variation across children's hospitals among infants with fractures evaluated for abuse, with the hypothesis that hospitals would vary substantially in neuroimaging practices. As a secondary objective, factors associated with neuroimaging use were identified, with the hypothesis that age and factors associated with potential biases (ie, payer type and race or ethnicity) would be associated with neuroimaging use.
Design, Setting, And Participants:
This cross-sectional study included infants with a femur or humerus fracture or both undergoing abuse evaluation at 44 select US children's hospitals in the Pediatric Health Information System (PHIS) from January 1, 2016, through March 30, 2020, including emergency department, observational, and inpatient encounters. Included infants were aged younger than 12 months with a femur or humerus fracture or both without overt signs or symptoms of head injury for whom a skeletal survey was performed. To focus on infants at increased risk for clinically occult head injuries, infants with billing codes suggestive of overt neurologic signs or symptoms were excluded. Multivariable logistic regression was used to investigate demographic, clinical, and temporal factors associated with use of neuroimaging. Marginal standardization was used to report adjusted percentages of infants undergoing neuroimaging by hospital and payer type. Data were analyzed from March 2021 through January 2022.
Exposures:
Covariates included age, sex, race and ethnicity, payer type, fracture type, presentation year, and hospital.
Main Outcomes And Measures:
Use of neuroimaging by CT or MRI.
Results:
Of 2585 infants with humerus or femur fracture or both undergoing evaluations for possible child abuse, there were 1408 (54.5%) male infants, 1726 infants (66.8%) who were publicly insured, and 1549 infants (59.9%) who underwent neuroimaging. The median (IQR) age was 6.1 (3.2-8.3) months. There were 748 (28.9%) Black non-Hispanic infants, 426 (16.5%) Hispanic infants, 1148 (44.4%) White non-Hispanic infants. In multivariable analyses, younger age (eg, odds ratio [OR] for ages <3 months vs ages 9 to <12 months, 13.2; 95% CI, 9.54-18.2; P < .001), male sex (OR, 1.47; 95% CI, 1.22-1.78; P < .001), payer type (OR for public vs private insurance, 1.48; 95% CI, 1.18-1.85; P = .003), fracture type (OR for femur and humerus fracture vs isolated femur fracture, 5.36; 95% CI, 2.11-13.6; P = .002), and hospital (adjusted range in use of neuroimaging, 37.4% [95% CI 21.4%-53.5%] to 83.6% [95% CI 69.6%-97.5%]; P < .001) were associated with increased use of neuroimaging, but race and ethnicity were not. Publicly insured infants were more likely to undergo neuroimaging (62.0%; 95% CI, 60.0%-64.1%) than privately insured infants (55.1%; 95% CI, 51.8%-58.4%) (P = .001).
Conclusions And Relevance:
This study found that hospitals varied in neuroimaging practices among infants with concern for abuse. Apparent disparities in practice associated with insurance type suggest opportunities for quality, safety, and equity improvement.
