Trends and Associations of Chest Radiography Utilization in Children With Asthma Exacerbations

Chest radiographs (CXRs) are often obtained among children presenting to the emergency department (ED) with an asthma exacerbation, despite guidelines recommending against their routine use. The clinical consequences and hospital-level variation of this practice remain unclear. This study's objective was to assess trends, interhospital variation, and factors associated with CXR utilization for asthma exacerbations across US pediatric EDs.

Using the Pediatric Health Information System (PHIS), we identified ED encounters for children aged 2 to 18 years with asthma between 2016 and 2024. Asthma exacerbations were identified using a combination of a discharge diagnosis code for asthma and receipt of albuterol during the ED encounter. We evaluated CXR trends, patient/hospital-level predictors, and downstream outcomes using multivariable logistic regression models.

CXRs were obtained in 145 059 children (22.3%). No significant temporal trend in overall CXR use was observed; however, CXR use declined among the subset of children diagnosed with pneumonia. Rates varied widely across hospitals (13.1%-37.7%). Higher CXR use was associated with younger age, female sex, white race, private insurance, and winter presentation. Hospitals with higher imaging rates had more pneumonia diagnoses and 3-day return visits but similar admissions, length of stay, and charges.

CXR utilization in pediatric asthma exacerbations is common, highly variable, and linked to increased pneumonia diagnoses and return visits. Persistent low-value imaging suggests hospital-level practices may influence diagnostic labeling and patient outcomes. Targeted interventions, such as decision support and benchmarking, are needed to reduce unnecessary imaging and promote equitable, evidence-based care in pediatric EDs.