Purpose or Case Report: Health system integration presents challenges for radiology departments, especially in standardizing imaging protocols across new affiliate sites. In pediatric radiology, these challenges are amplified when adult-focused centers begin serving children, as pediatric imaging often requires protocol modifications. Per ACR-SPR-SSR guidelines, pediatric dual-energy x-ray absorptiometry (DXA) should include lumbar spine and total body images, which provide a more accurate measurement of bone mineral density in children than the standard adult DXA protocol. In our integrated health system, radiologists noted inconsistent use of the pediatric DXA protocol at new affiliate sites. This quality improvement (QI) study evaluated adherence to pediatric DXA protocols across imaging sites to inform targeted interventions to improve national guideline compliance.
Methods & Materials: All DXA studies in one health system performed on patients ≤ 18 years and interpreted by pediatric radiologists between January 1, 2020, and October 14, 2025, were identified using mPower (Nuance, Burlington, MA). Exam protocol, imaging site, and patient age and sex were collected for each study. Percentage of exams adhering to the pediatric protocol (total body and lumbar spine images) was determined for each site.
Results: In the study period, 207 pediatric patients underwent 253 DXA exams. Median patient age was 16 (IQR 4), and 118 patients (57%) were female. At the flagship hospital, 190 of 204 studies (93%) adhered to the pediatric protocol. The remaining exam protocols were: 11 (5%) lumbar spine and hip; 1 lumbar spine; 1 hip; and 1 hip and forearm. At the four newly integrated community imaging sites, 7 of 47 studies (15%) adhered to the pediatric protocol. The remaining exam protocols were: 38 (81%) lumbar spine and hip; 1 lumbar spine; and 1 lumbar spine, hip, and forearm.
Conclusions: Pediatric DXA was an infrequently performed exam with significant variation in protocol adherence across sites. While health system consolidation provides increased access to imaging for our pediatric patients, these results show the importance of QI to monitor compliance with national pediatric imaging guidelines at all affiliate sites. This study’s methodology can serve as a framework for further QI analyses in this and other health systems. Based on these results and interviews with stakeholders, our team will design, implement, and assess the impact of targeted interventions to improve pediatric DXA protocol adherence across the health system.