Factors Influencing Temporal Trends in Pediatric Inpatient Imaging Utilization

Contemporary trends in utilization of pediatric cardiac imaging in children's hospitals

BACKGROUND

There has been an increase in availability and utilization of cardiac CT (CCT) and magnetic resonance (CMR) imaging in pediatric cardiology. Understanding trends in their utilization can provide foundational data for defining appropriate use of these tests in pediatrics, and guide resource distribution enhance access to these modalities.

METHODS

This retrospective observational study utilized data from the Pediatric Health Information Systems (PHIS) database, a clinical and billing database including 49 children's hospitals. Encounters between 2010 and 2023 that had a code for any cardiac imaging test (echocardiography, CCT, or CMR) were included. The proportion of encounters utilizing each cardiac imaging test per year was calculated, and the primary outcome was the change in this proportion.

RESULTS

A total of 95,021,317 hospital-based encounters were queried, of which 1,442,094 had at least one of the 3 tests performed. The total number of encounters utilizing any cardiac imaging test increased over the study period. The proportion of encounters with echocardiography decreased (by 6.5 ​%) while those with CMR and CCT increased (70 ​% and 200 ​% respectively) over the study period. There was variation in imaging utilization by geographic region and diagnosis.

CONCLUSION

This study highlights a marked increase in CCT use in pediatric cardiac imaging, accompanied by regional disparities in utilization. The growing role of CCT underscores the need for tailored training programs for pediatric cardiologists and increased resource allocation to meet rising demand. Future research should explore the drivers of regional variation and investigate the impact of modality choice on patient outcomes and care efficiency.

Incidence, Management, and Survival of Pancreatic Malignancies in Children: A Population-Based SEER Study

BACKGROUND

Pancreatic neoplasms are uncommon in children. We assessed the incidence, treatment, and survival of children with pancreatic malignancies, and determined factors associated with mortality using a large database.

METHODS

The Surveillance, Epidemiology, and End Results 22 database (excluding IL and MA) was queried to identify pediatric patients diagnosed with pancreatic malignancies between 2000 and 2020. Incidence, demographics, treatment modalities, and survival data were compared between tumor groups.

RESULTS

Pancreatic malignancies were identified in 300 patients (69 % female). Patients were classified by histology into solid pseudopapillary carcinoma (SPC; n = 144, 48 %), neuroendocrine (NET; n = 77, 25.7 %), epithelial (EP; n = 27, 9 %), pancreatoblastoma (PB; n = 30, 10 %), and non-epithelial/unknown (NE/U; n = 22, 7.3 %). Overall median age at diagnosis was 14, whereas median age for pancreatoblastoma was 4 (p < 0.001). Majority of SPCs (86.8 %) were diagnosed in females (p < 0.001). At diagnosis, 95 (56.2 %), 40 (23.7 %), and 34 (20.1 %) patients had localized, regional, and metastatic disease, respectively. Overall, 225 (86.2 %) patients underwent operation. Five-year overall survival rates at 5-years for each tumor group were significantly different (p < 0.001) at 100 %, 84.2 %, 69 %, 67.2 %, and 59 % for SPC, NET, NE/U, PB, and EP types, respectively. Age-adjusted incidence of pancreatic malignancies was 0.0424 per 100,000. Annual percent change in incidence from 2000 to 2020 was 9.9 [CI: (6.8,13.1), p < 0.001). Regional and distant disease, not undergoing operation, and certain tumor types were associated with increased mortality.

CONCLUSION

Pancreatic malignancy incidence increased over the last 20 years. Tumor type (pancreatoblastoma, neuroendocrine, and epithelial), advanced disease stage, and not undergoing surgery were independently associated with increased mortality.

TYPE OF STUDY

Retrospective cohort study.

LEVEL OF EVIDENCE

III.

Cardiovascular imaging in children with cardiac implantable electronic devices

The number of children with cardiac implantable electronic devices (CIEDs) is increasing at a time of rapid growth in cardiac magnetic resonance (MR) and cardiac computed tomography (CT) utilization. The presence of CIEDs poses challenges with respect to imaging safety and quality. A thoughtful approach to cardiovascular imaging in patients with CIEDs begins with an awareness of the clinical indications to determine the most appropriate imaging modality. Understanding device characteristics allows one to ensure that the proper safety measures are taken before and during cardiac MR and cardiac CT examinations. Despite the propensity of CIEDs to cause image artifact, several techniques are available to counteract these artifacts and preserve imaging quality.

Proposed resources required for a comprehensive program for CCT CHD imaging

BACKGROUND

Cardiac Computed Tomography (CCT) is increasingly used for evaluation of congenital heart disease (CHD) in patients of all ages. Pediatric and adult congenital heart disease (ACHD) surgical programs require high quality CCT imaging as part of the multimodality imaging support expected of comprehensive care centers. Despite these expectations, there are no benchmarks or defined programmatic elements specific to the performance of CCT in patients with CHD. To address this deficit, this manuscript is written by a group of current CHD CCT practitioners and provides a collective opinion regarding the clinical components required, and essential resources needed, to deliver a comprehensive CCT CHD imaging program. Resource allocation was divided into CCT technology, imaging technologist, physician and programmatic support. The group is inclusive of pediatric and adult cardiologists and radiologists and includes practitioners from high and lower resourced programs and countries. Imaging settings are inclusive of academic and private practice, heart centers and combined radiology/cardiology service lines. Challenges and areas for future advocacy to support this growing specialty are proposed to improve performance standards that will consider the expected widespread variation in technical and staffing resources, skillsets, and practice settings for CT in CHD.

SUMMARY

High quality cardiovascular computed tomography is an essential component of pediatric and adult congenital programs and surgical centers. Program growth outpaces resource allocation in most institutions. This opinion paper outlines essential components for technical, technologist and physician resources and programmatic support to develop and maintain a successful CCT in CHD program. Although a small component of most cardiac imaging programs, it is an essential component particularly in complex cases. Institutional and imaging societal commitment is essential to support this emerging field at highest quality.

"In-patient echocardiography utilization post repair of congenital heart disease. Analysis of data from the Pediatric Health Information System from 2010 to 2019"

BACKGROUND

Echocardiography is a key diagnostic tool for medical decision-making following congenital heart surgery. Overall utilisation of echocardiography for specific congenital heart lesions following cardiac surgery has not previously been reported. This study aims to assess echocardiogram utilisation following the surgical repair of CHD to describe the variation in use across centres and provide clinical benchmarks.

METHODS

All patients < 18 years of age undergoing surgical repair of CHD were identified from the Pediatric Health Information System from 2010 to 2019. Surgeries were grouped based on their Risk Adjustment for Congenital Heart Surgery-1 scores. Detailed billing data were used to assess the frequency/cost of post-operative echocardiograms, phase of hospital care, and hospital length of stay.

RESULTS

In total, 37,238 surgical encounters were identified for inclusion across 48 centres. Higher Risk Adjustment for Congenital Heart Surgery scores were associated with an increased median number of post-operative echocardiograms (2 versus 4 in Risk Adjustment for Congenital Heart Surgery score 1 versus 6, p < 0.001), and longer median post-operative length of stay (3 days versus 31 days in Risk Adjustment for Congenital Heart Surgery score 1 versus 6, p < 0.001). After accounting for surgical complexity, there was significant variability in echocardiogram utilisation across centres (median daily echocardiogram utilisation range 0.2/day-0.6/day, p < 0.001). There is no difference in the proportion of patients with high surgical complexity (Risk Adjustment for Congenital Heart Surgery ≥ 4) between centres with high versus low echocardiogram utilisation (p = 0.44).

CONCLUSIONS

Increasing surgical complexity is associated with longer post-operative length of stay and increased utilisation of echocardiography. There is wide variability in echocardiography resource utilisation across centres, even when accounting for surgical complexity.

Trends in cardiac CT utilization for patients with pediatric and congenital heart disease: A multicenter survey study

BACKGROUND

The use of cardiac CT (CCT) has increased dramatically in recent years among patients with pediatric and congenital heart disease (CHD), but little is known about trends and practice pattern variation in CCT utilization for this population among centers.

METHODS

A 21-item survey was created to assess CCT utilization in the pediatric/CHD population in calendar years 2011 and 2021. The survey was sent to all non-invasive cardiac imaging directors of pediatric cardiology centers in North America in September 2022.

RESULTS

Forty-one centers completed the survey. In 2021, 98% of centers performed CCT in pediatric and CHD patients (vs. 73% in 2011), and 61% of centers performed >100 CCTs annually (vs. 5% in 2011). While 62% of centers in 2021 utilized dual-source technology for high-pitch helical acquisition, 15% of centers reported primarily performing CCT on a 64-slice scanner. Anesthesia utilization, use of medications for heart rate control, and type of subspecialty training for physicians interpreting CCT varied widely among centers. 50% of centers reported barriers to CCT performance, with the most commonly cited concerns being radiation exposure, the need for anesthesia, and limited CT scan staffing or machine access. 37% (11/30) of centers with a pediatric cardiology fellowship program offer no clinical or didactic CCT training for categorical fellows.

CONCLUSION

While CCT usage in the CHD/pediatric population has risen significantly in the past decade, there is broad center variability in CCT acquisition techniques, staffing, workflow, and utilization. Potential areas for improvement include expanding CT scanner access and staffing, formal CCT education for pediatric cardiology fellows, and increasing utilization of existing technological advances.

Extracardiac Findings on Cardiac Magnetic Resonance: A Children's Hospital Experience

Cardiac magnetic resonance (CMR) incorporates a field of view that has the potential to capture clinically relevant extracardiac findings (ECF); however, there has been minimal investigation of ECF prevalence in children's hospitals, where the patient population varies in age and diagnosis. We retrospectively reviewed consecutive, clinically indicated, CMR studies performed at a tertiary care children's hospital during a 1-year period from January 1 to December 31, 2019. ECFs were classified as significant or non-significant based on whether they were described in the final impression of the CMR report. A total of 851 distinct patients had a CMR study during the 1-year period. Mean age was 19.5 (range 0.2; 74.2) years. A total of 254 ECFs were present in 158 of the 851 studies (18.6%) with 9.8% of all studies having significant ECFs. A total of 40.2% of ECFs were previously unknown and 9.1% (23/254) of ECFs included further recommendations (2.1% of all studies). ECFs were most often found in the chest (48%) or abdomen/pelvis (46%). Three patients were incidentally found to have malignancy (renal cell, thyroid, and hepatocellular carcinoma). Comparing studies with significant ECFs to the group without, CMR indications for biventricular CHD (43% vs 31%, p = 0.036), single ventricle CHD (12% vs 3.9%, p = 0.002), and aortopathy/vasculopathy (16% vs 7.6%, p = 0.020) were more common. The odds of significant ECF increased with increasing age (OR 1.82, 95% CI 1.10-3.01) and increased most notably between ages 14 to 33 years old. Recognition of the high percentage of ECFs remains important for timely diagnosis of these incidental findings.

Appropriateness of cardiovascular computed tomography and magnetic resonance imaging in patients with conotruncal defects

BACKGROUND

To promote the rational use of cardiovascular imaging in patients with congenital heart disease, the American College of Cardiology developed Appropriate Use Criteria (AUC), but its clinical application and pre-release benchmarks have not been evaluated. We aimed to evaluate the appropriateness of indications for cardiovascular magnetic resonance (CMR) and cardiovascular computed tomography (CCT) in patients with conotruncal defects and to identify factors associated with maybe or rarely appropriate (M/R) indications.

METHODS

Twelve centers each contributed a median of 147 studies performed prior to AUC publication (01/2020) on patients with conotruncal defects. To incorporate patient characteristics and center-level effects, a hierarchical generalized linear mixed model was used.

RESULTS

Of the 1753 studies (80% CMR, and 20% CCT), 16% were rated M/R. Center M/R ranged from 4 to 39%. Infants accounted for 8.4% of studies. In multivariable analyses, patient- and study-level factors associated with M/R rating included: age <1 year (OR 1.90 [1.15-3.13]), truncus arteriosus (vs. tetralogy of Fallot, OR 2.55 [1.5-4.35]), and CCT (vs. CMR, OR 2.67 [1.87-3.83]). None of the provider- or center-level factors reached statistical significance in the multivariable model.

CONCLUSIONS

Most CMRs and CCTs ordered for the follow-up care of patients with conotruncal defects were rated appropriate. However, there was significant center-level variation in appropriateness ratings. Younger age, CCT, and truncus arteriosus were independently associated with higher odds of M/R rating. These findings could inform future quality improvement initiatives and further exploration of factors resulting in center-level variation.

Use of advanced cardiac imaging in congenital heart disease: growth, indications and innovations

PURPOSE OF REVIEW

Significant improvements in the diagnosis and management of patients with congenital heart disease (CHD) have led to improved survival. These patients require life-long noninvasive evaluation. The use of advanced imaging such as cardiac magnetic resonance imaging (CMR) and cardiac computed tomography (CCT) has increased to support this need. The purpose of this review is to discuss the basics of advanced cardiac imaging, indications and review the recent innovations.

RECENT FINDINGS

Recent literature has demonstrated the increasing reliance of advanced imaging for CHD patients. In addition, research is focusing on CMR techniques to shorten scan time and address previous limitations that made imaging younger and sicker patients more challenging. CCT research has involved demonstrating high-quality images with low radiation exposure. Advances in digital technology have impacted the interactivity of 3D imaging through the use of virtual and augmented reality platforms. With the increased reliance of advanced imaging, appropriate use criteria have been developed to address possible under or over utilization.

SUMMARY

The utilization of advanced cardiac imaging continues to increase. As CMR and CCT continue to grow, increased knowledge of these modalities and their usage will be necessary for clinicians caring for CHD patients.