Hospital and Emergency Department Pediatric Capability, Patient Characteristics, and Radiology Imaging for Children

Judicious use of radiology imaging is an important quality measure in emergency care for children. Prior studies have shown differences in imaging utilization by insurance status and race and ethnicity.

To examine if measures of hospital and emergency department (ED) pediatric capabilities modify the association between insurance, race and ethnicity, and imaging utilization.

This retrospective cohort study combined data from the 2019 State Emergency Department and State Inpatient Databases of 8 states with the 2019 National Emergency Department Inventory-USA and the 2021 National Pediatric Readiness Project (NPRP) Survey on patients 18 years of age or younger. There were 857 034 total ED visits across 3 cohorts, encompassing patients with asthma, head trauma, or abdominal trauma. Statistical analysis was performed from May 2024 to January 2026.

Pediatric capability, as measured by presence of a pediatric emergency care coordinator, readiness according to NPRP data, and hospital functional capability (inpatient and intensive care unit bed status).

The association of insurance and race and ethnicity (separate models) with imaging utilization was examined across the 3 cohorts. Chest radiography was evaluated for patients with asthma, head computed tomography (CT) was evaluated for patients with head trauma, and abdominal CT was evaluated for patients with abdominal trauma. Separate mixed-effects logistic regression models were constructed, adjusting for age, sex, presence of a complex chronic condition, diagnostic grouping system severity score, hospital pediatric ED visit volume, and complexity of the hospital patient mix (percentage of patients with complex chronic conditions and mean severity clinical score) with random intercept for hospital. As a sensitivity analysis, these associations were examined separately for discharged patients.

There were 857 034 total ED visits in the 3 cohorts, encompassing patients with asthma (380 719 ED visits; mean [SD] age, 9.6 [5.0] years; 210 598 male [55%]), head trauma (435 644 ED visits; mean [SD] age, 7.2 [5.7] years; 264 004 male [61%]), and abdominal trauma (40 671 ED visits; mean [SD] age, 11.0 [5.4] years; 21 632 male [53%]). Children with public insurance were less likely to have undergone imaging across all measures compared with those with private insurance (asthma: adjusted odds ratio [AOR], 0.85 [95% CI, 0.83-0.86]; head trauma: AOR, 0.77 [95% CI, 0.75-0.78]; abdominal trauma: AOR, 0.59 [95% CI, 0.55-0.63]). In the adjusted model, compared with non-Hispanic White patients, non-Hispanic Black and Hispanic patients were less likely to have undergone imaging across all measures (non-Hispanic Black, asthma: AOR, 0.83 [95% CI, 0.81-0.85]; non-Hispanic Black, head trauma: AOR, 0.77 [95% CI, 0.74-0.79]; non-Hispanic Black, abdominal trauma: AOR, 0.60 [95% CI, 0.55-0.65]; Hispanic, asthma: AOR, 0.91 [95% CI, 0.89-0.93]; Hispanic, head trauma: AOR, 0.85 [95% CI, 0.82-0.87]; Hispanic, abdominal trauma: AOR, 0.72 [95% CI, 0.66-0.80]). The presence of pediatric capability was associated with differences in imaging utilization, but not with changes in the pattern of association between either insurance or race and ethnicity and imaging utilization. Similar results were observed among those who were discharged.

In this cohort study of pediatric ED visits, increased pediatric capability was not associated with differences in the patterns of imaging utilization by insurance status or race and ethnicity. Additional efforts are needed to ensure that pediatric capability improves quality and equity of care.