Trends and Associations of Chest Radiography Utilization in Children With Asthma Exacerbations

BACKGROUND AND OBJECTIVE: Chest radiographs (CXRs) are often obtained among children presenting to the emergency department (ED) with an asthma exacerbation, despite guidelines recommending against their routine use. The clinical consequences and hospital-level variation of this practice remain unclear. This study's objective was to assess trends, interhospital variation, and factors associated with CXR utilization for asthma exacerbations across US pediatric EDs. METHODS: Using the Pediatric Health Information System (PHIS), we identified ED encounters for children aged 2 to 18 years with asthma between 2016 and 2024. Asthma exacerbations were identified using a combination of a discharge diagnosis code for asthma and receipt of albuterol during the ED encounter. We evaluated CXR trends, patient/hospital-level predictors, and downstream outcomes using multivariable logistic regression models. RESULTS: CXRs were obtained in 145 059 children (22.3%). No significant temporal trend in overall CXR use was observed; however, CXR use declined among the subset of children diagnosed with pneumonia. Rates varied widely across hospitals (13.1%-37.7%). Higher CXR use was associated with younger age, female sex, white race, private insurance, and winter presentation. Hospitals with higher imaging rates had more pneumonia diagnoses and 3-day return visits but similar admissions, length of stay, and charges. CONCLUSIONS: CXR utilization in pediatric asthma exacerbations is common, highly variable, and linked to increased pneumonia diagnoses and return visits. Persistent low-value imaging suggests hospital-level practices may influence diagnostic labeling and patient outcomes. Targeted interventions, such as decision support and benchmarking, are needed to reduce unnecessary imaging and promote equitable, evidence-based care in pediatric EDs.