Cranial CT Use for Minor Head Trauma In Children Is Associated with Race/Ethnicity

Friday, October 14, 2011: 2:00 PM
Seaport Ballroom (Seaport Hotel)
JoAnne E. Natale, MD, PhD, FAAP, Department of Pediatrics, University of California, Davis, Sacramento, CA, Jill G. Joseph, MD, PhD, Center for Clinical and Community Research, George Washington University, Washington, DC, Alexander J. Rogers, M.D., Departments of Emergency Medicine and Pediatrics, University of Michigan Medical Center and University of Michigan School of Medicine, Ann Arbor, MI, Prashant Mahajan, MD, MPH, MBA, FAAP, Pediatrics, Children's Hospital of Michigan, Detroit, MI, Arthur Cooper, MD, FAAP, Pediatric Surgery, Columbia University College of Physicians and Surgeons at Harlem Hospital Center, New York, NY, David Wisner, MD, Department of Surgery, University of California, Davis, Sacramento, CA, Michelle L. Miskin, MS, PECARN/CDMCC, Salt Lake City, UT, John D. Hoyle, MD, Emergency Medicine, Helen DeVos Children's Hospital/Michigan State University, Grand Rapids, MI, Shireen M. Atabaki, MD, MPH, Emergency Medicine, Children's National Medical Center, Washington, DC, Peter S. Dayan, MD, MSc, Pediatric Emergency Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, James F. Holmes, MD, MPH, Department of Emergency Medicine, University of California, Davis, Sacramento, CA and Nathan Kuppermann, MD, MPH, FAAP, Emergency Medicine and Pediatrics, University of California, Davis School of Medicine, Sacramento, CA

Purpose: Racial disparities in healthcare are well documented and adversely affect the care provided to African American and Hispanic adults; this includes care provided in Emergency Departments (EDs). Less is known regarding disparities in pediatric ED care, including the use of cranial CT for minor head trauma.  Although the most commonly used imaging method for detection of traumatic brain injury (TBI), cranial CT provides appreciable radiation and increases the risk of subsequent lethal malignancies.  Therefore, we sought to determine if race/ethnicity are independently associated with use of cranial CT among children with minor head trauma evaluated in EDs.

Methods: We performed a secondary data analysis of a prospective cohort study of children < 18 years old with Glasgow Coma Scale scores 14-15 following minor head trauma who presented at 25 EDs in the Pediatric Emergency Care Applied Research Network (PECARN).  In this sub-study, we analyzed patients whose race and ethnicity was Hispanic, Non-Hispanic African American, or Non-Hispanic White.  We used generalized estimating equations (GEE) to control for hospital clustering and patient characteristics (age, gender, isolated head trauma, parent principal language, and risk of clinically-important TBI [ciTBI]) to compare CT rates among these racial/ethnic groups.  We defined ciTBI a priori as a TBI resulting in death, neurosurgery, intubation for > 24 hours, or ≥ 2 nights of hospitalization.  We used the validated PECARN ciTBI prediction rules to categorize children into lowest, intermediate, or higher risk groups. 

Results: Of the 42,412 children enrolled in the main study, 39,717 (94%) had a documented race/ethnicity of Hispanic, African American, or White.  Of these, 13,793 (35%) were imaged with CT.  Rates of CT use by race/ethnicity and by risk for ciTBI category are shown in the table.

 ciTBI risk

White (N=19,122)

African-American (N=15,425)

Hispanic (N=5,170)













Using GEE, we found no significant differences by race/ethnicity in the likelihood of receiving a CT among children at higher risk of ciTBI.  Among those at intermediate risk, Whites were significantly more likely to receive a CT than African Americans (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.08 to 1.37).  At the lowest risk of ciTBI, Whites were significantly more likely to receive a CT than African-Americans (OR, 1.41; 95% CI, 1.27 to 1.58) or Hispanics (OR, 1.30; 95% CI, 1.11 to 1.51).

Conclusion: After minor head trauma, ED use of cranial CT in children varies according to race/ethnicity.  Further studies should focus on explaining these racial differences in the use of emergent neuroimaging.

PECARN is supported by the Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB), Emergency Medical Services for Children Program. This study is supported by HRSA/MCHB grant number R40MC02461.