Radiologic studies are critical diagnostic tools, yet stewardship is essential to minimize ionizing radiation exposure and anesthesia events associated with childhood imaging. As a result, imaging reduction has become a popular deimplementation objective in the pediatric hospital setting. However, little is known about the relative prevalence of imaging across broad diagnostic categories. Understanding such patterns may help to prioritize imaging-oriented quality improvement efforts for distinct conditions. In this month's Journal of Hospital Medicine, Desai et al.1 explore imaging for medical and surgical conditions within the Pediatric Health Information System (PHIS) database. Analyzing >800,000 encounters from 2017 to 2019 at 50 hospitals, the authors identified common conditions with the greatest imaging prevalence and associated cost. In addition, they utilized an intraclass correlation coefficient (ICC) to assess variation in imaging costs within and between hospitals. Across all conditions, the use of any imaging was highest among encounters for pectus excavatum, scoliosis, and intestinal obstruction, while imaging costs were highest among fractures, trauma, and appendicitis. The authors identified frequent use of imaging for conditions in which it is typically discouraged, including asthma, bronchiolitis, and constipation. Conditions with high ICCs, specifically indicating wide variation in cost across hospitals (relative to within-hospital variation), included scoliosis, preseptal cellulitis, dental abscess, and retropharyngeal abscess.1 The authors' findings corroborate existing literature on imaging for medical conditions in hospitalized children. The high rates of x-rays observed for bronchiolitis, asthma, and constipation signal continued overuse of services not recommended by current clinical guidelines.1, 2 While this analysis cannot ascertain whether nuanced clinical features support a divergence from clinical guidelines in some cases, these data suggest a need for ongoing measurement and structured deimplementation of these services. Notably, the literature suggests that previously improving trends in non-recommended imaging, perhaps influenced by national campaigns focused on radiation reduction, have demonstrated reversal in recent years, with increasing rates of non-guideline-concordant imaging observed for some conditions.2 The authors estimate that imaging costs associated with bronchiolitis, asthma, and constipation exceeded $10 million over this study period,1 which may underestimate current costs given these trends. ICCs revealed high variation across hospitals in a subset of medical and medical/surgical conditions. The identified variation in imaging for preseptal cellulitis and retropharyngeal abscess aligns with literature suggesting variation in many aspects of care for these relatively common conditions, including antimicrobial and surgical management in addition to imaging approach.3, 4 The culmination of literature surrounding these conditions, including the current study, suggests a need for prospective trials and, as the authors note, clinical guideline development. The surgical data provided by this study are novel and warrant attention. Given the acuity associated with surgical diagnoses and procedures, high rates of imaging for these conditions may be expected. However, the hospital-level variation in imaging costs associated with encounters for conditions such as scoliosis and pectus excavatum has not, to our knowledge, been previously documented. Optimal pre- and postoperative care procedures associated with these conditions are not currently well described; variation identified in this study supports a need for a better understanding of imaging indications in these conditions, research exploring the association of imaging practices with clinical outcomes, and development of care pathways minimizing "routine" imaging that may not influence management. For both medical and surgical conditions, efforts to measure variation in care have advanced in recent years, optimizing opportunities for clinicians and improvers to efficiently measure comparative performance. Within PHIS, dashboards allow participating hospitals to access real-time performance data in a variety of areas, including some non-recommended imaging studies.2 The American College of Surgeons Pediatric National Surgical Quality Improvement Program offers participants access to comparative performance data surrounding common pediatric surgical procedures.5 As analytic capacity grows and real-time data become more accessible, there are new opportunities to leverage these tools to achieve standardization, particularly in areas where strong literature supports best practices. Analysis of center-specific data can prioritize improvement resources toward services where variation is high, allow identification of top performers who may share improvement best practices, and allow determination of objective utilization targets based on the range of performance demonstrated by hospitals. Hospitals with access to such infrastructure should develop methods of continuous data monitoring linking to improvement initiatives. Concurrently, attention is needed to develop measurement strategies viable in smaller hospitals, where many of the conditions studied by Desai et al. are cared for and where performance data availability remains scarce. The results of this study highlight that continued efforts are needed to delineate imaging best practices for some conditions, including a subset of costly surgical and medical/surgical conditions, while efforts toward guideline-compliant care are still warranted for several common medical diagnoses. Desai et al. also remind us that the incorporation of surgical data and diagnoses is a critical step as we aim to achieve high-value care in children's hospitals, supporting the ongoing development of quality leadership programs in pediatric surgery. The authors declare no conflicts of interest.

Alaina Shine

Reto Baertschiger

Samantha A. House

Journal of Hospital Medicine

JHM 是医院医学学会的同行评审出版物，每年出版 12 次。 JHM 出版的手稿涉及住院成人或儿童的护理。感兴趣的广泛领域包括 (1) 常见住院疾病的治疗； (2) 改善围手术期护理的方法； (3) 改善对有老年或儿科脆弱性（如行动不便或具有复杂纵向护理）的住院患者的护理； (4) 创新医疗服务或教育模式的评估； (5) 在急性期和急性期后连续护理过程中提高医疗保健质量、安全性和价值的方法； (6) 评估影响医院和急性期后护理的政策和支付变化。

The Journal of Hospital Medicine (JHM) is a peer-reviewed publication of the Society of Hospital Medicine, published 12 times a year. The manuscripts published in JHM focus on the care of hospitalized adults and children. Areas of interest include: 1. Treatment of common inpatient diseases; 2. Methods to improve perioperative care; 3. Enhancing care for hospitalized patients with geriatric or pediatric vulnerabilities (such as mobility issues or complex longitudinal care needs); 4. Evaluation of innovative healthcare service or educational models; 5. Methods to improve healthcare quality, safety, and value during acute and post-acute care transitions; 6. Assessment of policy and payment changes affecting hospital and post-acute care.

《Journal of Hospital Medicine》是医院医学学会的同行评审期刊，每年出版12期。该期刊发表的手稿主要涉及住院成人和儿童的护理。我们关注的领域包括：1. 常见住院疾病的治疗；2. 改善围手术期护理的方法；3. 提升对老年或儿科脆弱患者（如行动不便或需要复杂纵向护理的患者）的护理质量；4. 创新医疗服务或教育模式的评估；5. 在急性期及急性期后连续护理过程中提高医疗质量、安全性和价值的方法；6. 评估影响医院及急性期后护理的政策和支付变化。

Category	Quartile
医学	4
医学, 医学内科	3

Standardizing imaging practices: An opportunity to leverage modern measurement tools

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Journal Info

Category	Quartile
MEDICINE, GENERAL & INTERNAL	1