Initial Imaging for Adults With Maxillofacial Trauma in a National Claims Database

Plain radiography offers limited diagnostic value in maxillofacial trauma and is considered low-value care. Yet, when imaging is indicated, plain radiography remains commonly used despite guidelines favoring computed tomography (CT).

To examine national trends in, factors associated with, and consequences of low-value plain radiography use in the initial imaging of adults with maxillofacial trauma.

This retrospective cohort study used a population-based sample of administrative claims data from the Merative MarketScan Commercial Claims and Encounters Database from January 1, 2013, to December 31, 2022. Participants were adults aged 18 years or older with an International Classification of Diseases, Ninth Revision (ICD-9) or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnosis of facial trauma who received either plain radiography (nose, face, or orbit) or CT of the face or orbit within 7 days of diagnosis. Individuals with mandibular trauma, mandibular imaging, or prior facial imaging were excluded. Data were analyzed from December 2024 to June 2025.

Initial imaging modality for facial trauma: plain radiography (nose, face, or orbit) or CT (face or orbit).

The primary outcome was prevalence of low-value (plain radiography) imaging. Secondary outcomes included patient and practitioner characteristics associated with radiography use and downstream outcomes, including follow-up CT, diagnostic delays, and imaging-related costs. Multivariable logistic regression identified factors associated with low-value imaging.

Among 281 421 patients (mean [SD] age, 38.9 [15.0] years; 51.6% female), 72 125 (25.6%) received low-value plain radiography as their initial imaging. Plain radiography use declined from 32.9% of cases in 2013 to 18.0% in 2022. Female vs male sex (odds ratio [OR], 1.50; 95% CI, 1.47-1.54), being seen in an urgent care vs office-based setting (OR, 1.76; 95% CI, 1.67-1.87), and being seen by a family medicine practitioner vs an internist (OR, 1.43; 95% CI, 1.33-1.54) were associated with low-value imaging. In contrast, being seen by a surgical specialist vs internist (OR, 0.09; 95% CI, 0.08-0.11) or in an emergency department vs office setting (OR, 0.07; 95% CI, 0.07-0.07) were associated with significantly lower odds of receiving low-value imaging. In all, 5.5% of radiograph recipients underwent follow-up CT within 7 days, and 7.6% experienced a diagnostic delay. Although median total costs were lower for plain radiography ($56 [IQR, $29-$139]) than CT ($378 [IQR, $89-$845]), radiograph vs CT represented a greater proportion of total (mean [SD], 26% [24%] vs 21% [21%]) and out-of-pocket (mean [SD], 22% [30%] vs 15% [24%]) costs in low-acuity settings.

In this cohort study of adults with maxillofacial trauma, low-value plain radiography was frequently used despite clear guidelines favoring CT. Targeted interventions to reduce low-value imaging may improve diagnostic accuracy, reduce unnecessary costs, and advance value-based care.