SAN DIEGO – Hospitals treating neurologically impaired children with pneumonia typically have the best clinical outcomes, shortest lengths of stay, and lowest readmission rates when fewer diagnostic tests are performed.
This suggests that testing protocols across hospital centers should be standardized so clinicians perform as few testing procedures as possible, thus ensuring an elevated standard of care, said Dr. Joanna E. Thomson, a pediatric hospitalist at the Cincinnati Children’s Hospital Medical Center.
Dr. Joanna E. Thomson
“This population of children accounts for an increasing and disproportionate amount of inpatient hospital resources,” Dr. Thomson said at the annual meeting of the Pediatric Academic Societies. “While they represent just 14% of pediatric admissions, they account for 25% of pediatric hospital days and 30% of pediatric hospital charges.”
As defined by Dr. Thomson and her coinvestigators, neurological impairment (NI) was defined as any “neurologic disease resulting in functional or intellectual impairment,” such as cerebral palsy or epilepsy. Within the population of children with NI, pneumonia is a common reason for intensive care unit admission and the most common cause of death, but diagnostic testing, treatment, and outcomes vary widely from center to center.
After reviewing data on all children aged 1-18 years admitted to one of 40 U.S. children’s hospitals in the Pediatric Health Information Systems (PHIS) database for pneumonia from 2007 to 2012, Dr. Thomson and her associates selected 28,123 subjects for inclusion in the retrospective cohort study. The study had two primary outcomes: assess the variability of diagnostic testing performed at each center and determine the association of hospital-level diagnostic test utilization and hospitalization outcomes, mainly length of stay and 30-day readmission rates.
K-mean clustering was used to divide each hospital center into one of three groups – A, B, or C – based on diagnostic testing habits, with the proportion of patients receiving such testing compared across all included centers. Diagnostic testing was defined as laboratory studies and radiologic imaging ordered within the first 48 hours of admission. Kruskal-Wallis tests were used to compare the outcomes at each hospital.
Hospital centers in group C tended to perform significantly fewer tests than those in groups A and B, Dr. Thomson said.
Complete blood counts were performed on 56% of patients in group C centers, compared with 78% in group A and 72% in group B. Similarly, C-reactive protein tests were administered to 17% of patients in group A, 34% in group B, and 15% in group C. Viral studies were done on 24% of patients in group C, but 44% in group A and 52% in group B. Blood cultures were taken from 44% of patients in group C, but 63% in group A and 66% in group B. Urine culture tests were performed for 9% in group C, 22% of patients in group A, and 17% in group B, she reported.
The only test measured for which group C was not the lowest was respiratory culture: group C centers tested 5% of patients, while those in group A tested 15% and group B only tested 3% of patients.
Length of stay and 30-day readmission rates also were consistently lower for group C than groups A and B. Median length of stay across groups was 3.2 days; no hospital center in group C had a mean length of stay higher than 3.2, compared with 14 centers in group A and 5 in group B. The median 30-day readmission rate was 7.9% across all groups, a rate exceeded by 11 group A centers, 6 group B centers, and only 2 group C centers.
“We found [that] substantial hospital level variation exists in both diagnostic testing and outcomes,” Dr. Thomson said, adding that, since centers performing the fewest tests yielded the best outcomes, the findings here “represent an opportunity to improve the value of care provided to this important pediatric population” and that “overall testing can likely decrease without compromising the care we provide.”
Dr. Thomson did not report any relevant financial disclosures.