Reducing Unnecessary Imaging for Patients With Constipation in the Pediatric Emergency Department

Assessing fecal load with ultrasound in children with colorectal pathology: ReKiSo study

PURPOSE

To evaluate bowel management for children with colorectal pathology by measuring transverse rectal diameter (TRD) and assessing fecal load with transabdominal rectal ultrasound (TRU).

METHODS

Prospective case-control study of children receiving bowel management (BM) between 04/2023 and 04/2024 was done. There was inclusion of patients with Hirschsprung disease (HD), anorectal malformation (ARM) and functional constipation (FC). Patients with other congenital or neurological conditions were excluded. Control group consisted of inpatients and outpatients without abdominal complaints. FC was diagnosed according to ROM-IV-criteria. For HD and ARM, we followed a list of symptoms. To assess fecal load, we visualized the TRD using the Klijn (Klijn et al. in J Urol 172:1986-1988, 2004) method. The bladder was moderately full. The fecal load was assessed retrograde from the rectum. Follow-up was at 1/3/6 months. Secondary data were collected from medical records. Sample size calculated a priori and follow-up group with new gathered data.

RESULTS

p value for TRD in all groups significant with p < 0.05 and in grouped follow-up.

CONCLUSION

Ultrasound is a useful tool for assessing fecal load and helps diagnose constipation and monitor BM. Irrespective of colorectal pathology, a cut-off of 3 cm seems to discriminate between children without constipation/overload symptoms and asymptomatic patients. We present a radiation-free method for monitoring bowel management.

Meta-analysis: Intestinal ultrasound to evaluate colonic contents and constipation

BACKGROUND

Constipation can be diagnosed clinically using the Rome criteria. Ultrasound (US), which lacks the radiation exposure of conventional X-ray, holds promise as a non-invasive tool to evaluate colonic contents and constipation.

AIM

To examine the role of US in the assessment of constipation.

METHODS

We performed a systematic search of Embase (OVID, 1984), Medline (Ovid, 1946), Cochrane Central, ClinicalTrials.gov and Australia New Zealand Clinical Trials Registry from database inception to 26 January 2024 according to PRISMA guidelines and prospectively registered with PROSPERO. All studies using US to assess constipation or colonic contents in either adults or children were included. Rectal diameter measurements were pooled in meta-analysis. Risk of bias was assessed using the Newcastle Ottawa Scales and Joanna Briggs Institute checklists.

RESULTS

Of 12,232 studies screened, 51 articles (6084 patients; 3422 children) describing US to assess symptoms in patients with constipation were included. Most studies used Rome criteria to diagnose constipation. Rectal diameter was associated with clinical constipation in 29 paediatric studies (3331 patients). Meta-analysis showed the mean rectal diameter of constipated patients was significantly higher than controls (mean difference 12 mm, 95% confidence intervals (CI): 6.48, 17.93, p < 0.0001, n = 16 studies). Other features of constipation on US included posterior acoustic shadowing and echogenicity of luminal contents.

CONCLUSION

US is an appealing imaging modality to assess luminal contents and constipation. Further well-designed studies are required to validate US metrics that accurately identify constipation.

Use of rational subgrouping to understand variation and opportunity for improvement in time to ultrasound

OBJECTIVE

To understand factors that contribute to variation in time to abdominal and/or pelvic ultrasound in pediatric patients in an emergency department (ED) by utilizing rational subgrouping to assess opportunity for improvement.

METHODS

All abdominal and pelvic ultrasounds conducted in the Alberta Children's Hospital ED from May 2019 to April 2021 were included. Time of study order and time of study completion were obtained from the electronic health record. Statistical process control (SPC) I-charts were used to analyze the quarterly median number of minutes from ultrasound order to completion. Rational subgrouping was used to stratify the data based on sex, age, and ED shift type, and identify special cause variation between groups. Findings were used to inform local decision-making.

RESULTS

Special cause variation was detected among subgroups for sex, age group, and shift type. The median time from order of an abdominal and/or pelvic ultrasound to completion of study was 155 min. Females had a median order to completion time of 178 min, while males had a completion time of 131 min. From age 0 to 3, the median time was 110 min, compared to 149 min for ages 4 to 11 and 171 min for ages 12 and older. Day shifts had a median order to completion time of 145 min, compared to 129 min for evening shifts and 269 min for night shifts.

CONCLUSIONS

Longer time to study completion was observed in female patients, older patients, and during night shifts. Use of rational subgrouping supported understanding of variation among subgroups of patients evaluated with abdominal and/or pelvic ultrasound. This allowed informed decision-making regarding opportunities for improvement. Rational subgrouping is a useful methodology in planning QI initiatives as it identifies sources of variation within a nonhomogeneous population and allows for judicious decision-making in a context of limited resources.

Imaging in pediatric disorders of the gut-brain interactions: current best practice and future directions

INTRODUCTION

Disorders of Gut-Brain Interactions (DGBI) are a common clinical problem in children and pose significant challenges to the attending pediatrician. Radiological investigations are commonly ordered to evaluate these children.

AREA COVERED

This review focuses on the current best practice of using radiological investigations in DGBIs and how novel radiological investigations could revolutionize the assessment and therapeutic approach of DGBI in children.

EXPERT OPINION

We believe imaging in DGBI is still in its early stages, but it has the potential to revolutionize how we diagnose and treat children with DGBI. As the understanding of the gut-brain axis continues to grow, we can expect to see the disappearance of conventional imaging techniques and the emergence of more sophisticated imaging techniques with less radiation exposure in the future which provide more clinically meaningful information regarding the gut-brain axis and its influence on intestinal function. Some of the novel imaging modalities will be able to broaden our horizon of understanding DGBI in children providing more useful therapeutic options to minimize their suffering.

Decreasing Radiation Exposure to the Abdomen in Children with Chronic Constipation

Background

Bowel management for children with chronic constipation may include repeated single-view abdomen radiographs (AXR) to monitor treatment success. Only one image of the abdomen is needed to include most of the colon, but technologists often make a second (or even third) exposure to be sure they have imaged the entire abdomen. Our quality improvement project aimed to reduce radiation exposure by decreasing the frequency of >1 exposure performed for AXR orders in children with chronic constipation from 27% to <10% by December 2022 and sustain.

Methods

We counted baseline (01/2020-11/2020) and intervention (12/2020-5/2023) examinations with >1 exposure. Initial interventions were a structured communication to technologists and an article in the monthly department newsletter and later, a technologist education module. Additional interventions included communication to radiologists, project updates and encouragement to all technologists, and individual technologist feedback. A statistical process control chart tracked data to study process changes over time.

Results

During the baseline and intervention periods, 525/1944 and 1329/8334 examinations, respectively, had >1 exposure performed for AXR orders. Interventions created 2 centerline shifts. Overall, examinations with >1 exposure decreased from 27% to 13.5%.

Conclusions

Frequency of >1 exposure performed for AXR orders in children with chronic constipation decreased from 27% to 13.5% through education and communication. This was sustained. We plan to assign training modules for all new technologists, policy reminders (annual training in odd years) for all technologists, and continue individualized learning opportunities.

A Quality Improvement Initiative to Reduce Abdominal X-ray use in Pediatric Patients Presenting with Constipation

OBJECTIVE

To decrease the percentage of patients undergoing an abdominal radiograph for evaluation of constipation within 24 hours of their initial gastroenterology visit.

STUDY DESIGN

In January 2015, we implemented a quality improvement, evidence-based guideline (EBG) aimed at standardizing the initial assessment of patients presenting for a new outpatient gastroenterology visit with a primary complaint of constipation. Over the subsequent 5 years, we followed the clinical impact of this guideline initiation with the goal of decreasing unnecessary abdominal radiograph use by 10% within 1 year of EBG launch. Patients older than 6 months and younger than 19 years were included.

RESULTS

In total, 6723 patients completed new patient gastroenterology visits for a primary diagnosis of constipation between 2013 and 2019. Of these, 993 (14.8%) patients had abdominal radiographs taken within 24 hours of their initial visit. Over the 7 years of this project, a mean frequency of abdominal radiograph use decreased from 24% to less than 11%. In addition, a 57% decrease in hospital charges related to decreased radiograph use for constipation was found. No increases in subsequent emergency department visits or hospitalization for constipation within 30 days of patients' initial visits were seen.

CONCLUSIONS

Through local adoption of an EBG, routine use of abdominal radiographs taken during a patient's initial outpatient gastroenterology visit for constipation decreased by more than 50%. This reduction was maintained over a subsequent 5-year period without any detrimental side effects.

Racial and ethnic differences in low-value pediatric emergency care

BACKGROUND

Disparities in health care quality frequently focus on underuse. We evaluated racial/ethnic differences in low-value services delivered in the pediatric emergency department (ED).

METHODS

We performed a retrospective cross-sectional study of low-value services in children discharged from 39 pediatric EDs from January 2018 to December 2019 using the Pediatric Hospital Information System. Our primary outcome was receipt of one of 12 low-value services across nine conditions, including chest radiography in asthma and bronchiolitis; beta-agonist and corticosteroids in bronchiolitis; laboratory testing and neuroimaging in febrile seizure; neuroimaging in afebrile seizure; head injury and headache; and any imaging in sinusitis, constipation, and facial trauma. We analyzed the association of race/ethnicity on receipt of low-value services using generalized linear mixed models adjusted for age, sex, weekend, hour of presentation, payment, year, household income, and distance from hospital.

RESULTS

We included 4,676,802 patients. Compared with non-Hispanic White (NHW) patients, non-Hispanic Black (NHB) and Hispanic patients had lower adjusted odds (aOR [95% confidence interval]) of receiving imaging for asthma (0.60 [0.56 to 0.63] NHB; 0.84 [0.79 to 0.89] Hispanic), bronchiolitis (0.84 [0.79 to 0.89] NHB; 0.93 [0.88 to 0.99] Hispanic), head injury (0.84 [0.80 to 0.88] NHB; 0.80 [0.76 to 0.84] Hispanic), headache (0.67 [0.63 to 0.72] NHB; 0.83 [0.78 to 0.88] Hispanic), and constipation (0.71 [0.67 to 0.74] NHB; 0.76 [0.72 to 0.80] Hispanic). NHB patients had lower odds (95% CI) of receiving imaging for afebrile seizures (0.89 [0.8 to 1.0]) and facial trauma (0.69 [0.60 to 0.80]). Hispanic patients had lower odds (95% CI) of imaging (0.57 [0.36 to 0.90]) and blood testing (0.82 [0.69 to 0.98]) for febrile seizures. NHB patients had higher odds (95% CI) of receiving steroids (1.11 [1.00 to 1.21]) and beta-agonists (1.38 [1.24 to 1.54]) for bronchiolitis compared with NHW patients.

CONCLUSIONS

NHW patients more frequently receive low-value imaging while NHB patients more frequently receive low-value medications for bronchiolitis. Our study demonstrates the differences in care across race and ethnicity extend to many services, including those of low value. These findings highlight the importance of greater understanding of the complex interaction of race and ethnicity with clinical practice.

Approach to Abdominal Imaging in 2022

Abdominal pain represents 5% to 7% of all emergency department presentations. Many patients require imaging for diagnosis, and choosing the appropriate imaging modality is a crucial decision point. Modern medicine offers a fantastic array of options including abdominal radiograph, computed tomography, MRI, and ultrasonography, but the plethora of alternatives can be paralyzing. This article introduces the commonly available modalities, discusses the advantages and disadvantages, and presents current recommendations for commonly diagnosed conditions.

Interventions to reduce low-value imaging - a systematic review of interventions and outcomes

BACKGROUND

It is estimated that 20-50% of all radiological examinations are of low value. Many attempts have been made to reduce the use of low-value imaging. However, the comparative effectiveness of interventions to reduce low-value imaging is unclear. Thus, the objective of this systematic review was to provide an overview and evaluate the outcomes of interventions aimed at reducing low-value imaging.

METHODS

An electronic database search was completed in Medline - Ovid, Embase-Ovid, Scopus, and Cochrane Library for citations between 2010 and 2020. The search was built from medical subject headings for Diagnostic imaging/Radiology, Health service misuse or medical overuse, and Health planning. Keywords were used for the concept of reduction and avoidance. Reference lists of included articles were also hand-searched for relevant citations. Only articles written in English, German, Danish, Norwegian, Dutch, and Swedish were included. The Mixed Methods Appraisal Tool was used to appraise the quality of the included articles. A narrative synthesis of the final included articles was completed.

RESULTS

The search identified 15,659 records. After abstract and full-text screening, 95 studies of varying quality were included in the final analysis, containing 45 studies found through hand-searching techniques. Both controlled and uncontrolled before-and-after studies, time series, chart reviews, and cohort studies were included. Most interventions were aimed at referring physicians. Clinical practice guidelines (n = 28) and education (n = 28) were most commonly evaluated interventions, either alone or in combination with other components. Multi-component interventions were often more effective than single-component interventions showing a reduction in the use of low-value imaging in 94 and 74% of the studies, respectively. The most addressed types of imaging were musculoskeletal (n = 26), neurological (n = 23) and vascular (n = 16) imaging. Seventy-seven studies reported reduced low-value imaging, while 3 studies reported an increase.

CONCLUSIONS

Multi-component interventions that include education were often more effective than single-component interventions. The contextual and cultural factors in the health care systems seem to be vital for successful reduction of low-value imaging. Further research should focus on assessing the impact of the context in interventions reducing low-value imaging and how interventions can be adapted to different contexts.

Superior mesenteric artery syndrome: A review of the literature

Decreased intraabdominal fat can lead to intraabdominal compressive syndromes, such as superior mesenteric artery (SMA) syndrome. This phenomenon is rare but should be considered in a patient with recent rapid weight loss and acute gastrointestinal complaints. A delay in diagnosis and treatment can lead to severe complications, such as a gastric rupture. We report a case of SMA syndrome in a teenage male with recent intentional weight loss and intractable emesis, and the possible associations of SMA syndrome and Nutcracker syndrome.

Evidence-based Standardization of Constipation Management in the Emergency Department: A Quality Improvement Study

Supplemental Digital Content is available in the text.

Constipation is a common problem in pediatric patients. Abdominal radiographs (AXRs) are frequently obtained in the pediatric emergency department for diagnosis despite their poor reliability to rule out underlying pathology or prognostic ability to determine the degree of constipation. The goal of this quality improvement (QI) initiative was to standardize the diagnosis and management of constipation in the pediatric emergency department and urgent care in patients ages 6 months to 21 years and decrease AXR use by 20% and sustain this reduction for 12 months.

Reducing Abdominal Radiographs to Diagnose Constipation in the Pediatric Emergency Department

OBJECTIVE

To determine the frequency of abdominal radiographs obtained in healthy children aged 6 months to 18 years to diagnose constipation in a pediatric emergency department, and evaluate the impact of quality improvement (QI) interventions on their use.

STUDY DESIGN

QI study over 2.5 years at a large urban quaternary care children's hospital emergency department. Interventions consisted of educational presentations and individualized abdominal radiograph data reporting. The primary outcome measure was the percentage of abdominal radiographs performed on healthy patients discharged home with a diagnosis of constipation before and after QI interventions.

RESULTS

The baseline total percentage of abdominal radiographs performed in otherwise healthy children discharged home with a diagnosis of constipation was 36% (October 2016 to January 2018). According to questionnaire results, ruling out obstruction was the most common reason for ordering an abdominal radiograph. After the QI interventions, the total percentage of abdominal radiograph decreased to 18% (April 2018 to March 2019). This 18% decrease was significant (P < .001) and sustained over a 12-month follow-up period. Throughout the study period, the average length of stay was 1.07 hours longer for children who had an abdominal radiograph. Clinically important return visits to the emergency department were uncommon during the postintervention phase (125/1830 [6.8%]), and not associated with whether or not an abdominal radiograph was performed at the initial visit.

CONCLUSION

After these QI interventions, we noted a significant and sustained decrease in the percentage of abdominal radiographs obtained for otherwise healthy patients discharged home with a diagnosis of constipation.

Low-Value Diagnostic Imaging Use in the Pediatric Emergency Department in the United States and Canada

IMPORTANCE

Diagnostic imaging overuse in children evaluated in emergency departments (EDs) is a potential target for reducing low-value care. Variation in practice patterns across Canada and the United States stemming from organization of care, payment structures, and medicolegal environments may lead to differences in imaging overuse between countries.

OBJECTIVE

To compare overall and low-value use of diagnostic imaging across pediatric ED visits in Ontario, Canada, and the United States.

DESIGN, SETTING, AND PARTICIPANTS

This study used administrative health databases from 4 pediatric EDs in Ontario and 26 in the United States in calendar years 2006 through 2016. Individuals 18 years and younger who were discharged from the ED, including after visits for diagnoses in which imaging is not routinely recommended (eg, asthma, bronchiolitis, abdominal pain, constipation, concussion, febrile convulsion, seizure, and headache) were included. Data analysis occurred from April 2018 to October 2018.

EXPOSURES

Diagnostic imaging use.

MAIN OUTCOME AND MEASURES

Overall and condition-specific low-value imaging use. Three-day and 7-day rates of hospital admission and those admissions resulting in intensive care, surgery, or in-hospital mortality were assessed as balancing measures.

RESULTS

A total of 1 783 752 visits in Ontario and 21 807 332 visits in the United States were analyzed. Compared with visits in the United States, those in Canada had lower overall use of head computed tomography (Canada, 22 942 [1.3%] vs the United States, 753 270 [3.5%]; P < .001), abdomen computed tomography (5626 [0.3%] vs 211 018 [1.0%]; P < .001), chest radiographic imaging (208 843 [11.7%] vs 3 408 540 [15.6%]; P < .001), and abdominal radiographic imaging (77 147 [4.3%] vs 3 607 141 [16.5%]; P < .001). Low-value imaging use was lower in Canada than the United States for multiple indications, including abdominal radiographic images for constipation (absolute difference, 23.7% [95% CI, 23.2%-24.3%]) and abdominal pain (20.6% [95% CI, 20.3%-21.0%]) and head computed tomographic scans for concussion (22.9% [95% CI, 22.3%-23.4%]). Abdominal computed tomographic use for constipation and abdominal pain, although low overall, were approximately 10-fold higher in the United States (0.1% [95% CI, 0.1%-0.2%] vs 1.2% [95% CI, 1.2%-1.2%]) and abdominal pain (0.8% [95% CI, 0.7%-0.9%] vs 7.0% [95% CI, 6.9%-7.1%]). Rates of 3-day and 7-day post-ED adverse outcomes were similar.

CONCLUSIONS AND RELEVANCE

Low-value imaging rates were lower in pediatric EDs in Ontario compared with the United States, particularly those involving ionizing radiation. Lower use of imaging in Canada was not associated with higher rates of adverse outcomes, suggesting that usage may be safely reduced in the United States.

Implementing a Standardized Constipation-Management Pathway to Reduce Resource Utilization

OBJECTIVE

Constipation is commonly diagnosed in our pediatric emergency department (ED). Care has varied significantly, with a heavy reliance on abdominal radiography (AR) for the diagnosis of and inpatient management for bowel cleanout. We implemented a standardized approach to caring for patients presenting to a pediatric ED with symptoms consistent with constipation, emphasizing clinical history, physical examination, less reliance on AR, and standardized home management.

METHODS

Using quality improvement (QI) methodology, a multidisciplinary group developed an ED constipation management pathway, encouraging less reliance on AR for diagnosis and promoting home management over inpatient bowel cleanout. The pathway included a home management "gift basket" containing over-the-counter medications and educational materials to promote successful bowel cleanout. Outcome measures included pathway utilization, AR rate, ED cost and length of stay, and ED admission rate for constipation.

RESULTS

Within 3 months, >90% of patients discharged home with an ED disposition diagnosis of constipation left with standardized educational materials and home medications. Staff education and feedback, pathway and gift basket changes, and a higher threshold for inpatient management led to significant decreases in AR rate (73.3%-24.6%, P < .001), average per-patient cost ($637.42-$538.85), length of stay (223-196 minutes, P < .001), and ED admission rate (15.3%-5.4%, P < .001), with no concerning missed diagnoses or increases in ED revisit rate.

CONCLUSIONS

An ED QI project standardizing the care of pediatric constipation was implemented successfully, leading to a sustainable decrease in resource utilization. The next phase of the project will focus on collaborating with community providers to reduce ED utilization.

A pragmatic comparative study of palliative care clinician's reports of the degree of shadowing visible on plain abdominal radiographs

The assessment of constipation symptoms is based on history and physical examination. However, the experience is highly subjective perhaps explaining why palliative medicine doctors continue to use plain abdominal radiographs as part of routine assessment of constipation. Previous studies have demonstrated poor agreement between clinicians with this work in palliative care, limited further by disparity of clinicians' experience and training. The aim of this work was to explore whether there was less variation in the assessments of faecal shadowing made by more experienced clinicians compared to their less experienced colleagues. This pragmatic study was conducted across six palliative care services in Sydney (NSW, Australia). Doctors of varying clinical experience were asked to independently report their opinions of the amount of shadowing seen on 10 plain abdominal radiographs all taken from cancer patients who self-identified themselves as constipated. There were 46 doctors of varying clinical experience who participated including qualified specialists, doctors in specialist training and lastly, doctors in their second- and third post-graduate years. Poor agreement was seen between the faecal shadowing scores allocated by doctors of similar experience and training (Fleiss's kappa (FK): RMO 0.05; registrar 0.06; specialist 0.11). Further, when the levels of agreement between groups were considered, no statistically significant differences were observed. Although the doctors did not agree on the appearance of the film, the majority felt they were able to extrapolate patients' experiences from the radiograph's appearance. As it remains challenging in palliative care to objectively assess and diagnose constipation by history and imaging, uniform and objective assessment and diagnostic criteria are required. It is likely that any agreed criteria will include a combination of imaging and history. The results suggest the use of radiographs alone to diagnose and assess constipation in palliative care represents low value care.

Constipation Management in Pediatric Primary Care

Constipation is a common and often difficult to manage problem encountered in outpatient primary care. Although we give our patients many different modalities to treat constipation (eg, diet changes, behavior modification, probiotics, medication), there is little evidence to support any of these modalities. We also tend to order unnecessary tests during the diagnostic process. This article tries to clarify the diagnostic process and provide a clear treatment path to be used for functional constipation. [Pediatr Ann. 2018;47(5):e180-e184.].

The Role of Non-invasive Testing in Evaluation and Diagnosis of Pediatric Lower Urinary Tract Dysfunction

PURPOSE OF REVIEW

The symptoms of lower urinary tract dysfunction (LUTD) including urinary incontinence, frequency, and urgency are among the most common reasons children are referred to pediatric urologists. Despite this, the workup for LUTD is often time consuming and a source of frustration for patients, parents, and clinicians alike. In the current review, we summarize the important role non-invasive testing plays in the diagnosis and management of children with LUTD and to show how use of these tests can help avoid the need for more invasive testing in the majority of children.

RECENT FINDINGS

Non-invasive tests such urine studies, uroflowmetry ± simultaneous electromyography, assessment of post-void residual, renal/bladder ultrasound, and pelvic ultrasound when used appropriately can provide valuable information to facilitate decision making during the evaluation of children with LUTD. While these tests should be employed prior to more invasive testing such as urodynamic studies, they can often act as a surrogate for the more invasive tests. Non-invasive tests can help us in our goal of improving diagnostic ability to better classify the child's LUTD into an actual condition which allows targeted treatment in the hope of better outcomes and more satisfied patients and families.

Constipation-Related Emergency Department Use, and Associated Office Visits and Payments Among Commercially Insured Children

OBJECTIVE

Pediatric constipation is common, costly, and often managed in the Emergency Department (ED). The objectives of this study were to determine the frequency of constipation-related ED visits in a large commercially insured population, the frequency of an office visit in the month before and after these visits, demographic characteristics associated with these office visits, and the ED-associated payments.

METHODS

Data were extracted from the Truven MarketScan database for commercially insured children from 2012 to 2013. Data on the presence and timing of clinic visits within 30 days before and after an ED constipation visit and demographic variables were extracted. Logistic regression was used to predict an outcome of presence of a visit with independent variables of age, sex, and region of the country.

RESULTS

In a population of 17 million children aged 0 to 17 years, 448,440 (2.6%) were identified with constipation in at least 1 setting, with 65,163 (14.5%) having an ED visit for constipation. Of all children with a constipation-related ED visit, 45% had no office visit in the 30 days before or after the ED visit. Increasing age was associated with absence of an office visit. The median payment by insurance for an ED constipation visit was $523, the median out-of-pocket payment was $100, for a total of $623 per visit.

CONCLUSION

One in 7 children with constipation in this commercially insured population received ED care for constipation, many without an outpatient visit in the month before or after. Efforts to improve primary care utilization for this condition should be encouraged.