July 23, 2013
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More testing for CAP increased hospitalization rates

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EDs that use more testing to diagnose community-acquired pneumonia in children have higher hospitalization rates compared with lower-utilizing EDs, according to recent study findings.

“The significant across-hospital variation in diagnostic tests performed in the ED for childhood [community-acquired pneumonia (CAP)] illustrates the need to improve the quality of care provided,” Todd A. Florin, MD, MSCE, FAAP of the division of emergency medicine at the University of Cincinnati College of Medicine, and colleagues wrote in a study published in Pediatrics. “If overutilization can be diminished, there is the potential to decrease unnecessary hospitalization, decrease costs, prevent unnecessary hospital-acquired infections, and potentially improve short-term quality of life in children with CAP.”

 

Todd A. Florin

The retrospective cohort study included 100,615 ED visits resulting in CAP diagnoses from 2007 to 2010 in children aged 2 months to 18 years.

Researchers found that the most commonly ordered ED diagnostic tests were complete blood count (28.7%), blood culture (27.9%) and chest radiograph (75.7%). Significant variation (P<.001) was found for each test examined across hospitals after adjustment for patient and hospital characteristics. Hospitals utilizing tests at high rates had increased odds of hospitalization compared with low-utilizing hospitals (OR=1.86; 95% CI, 1.17-2.94). Revisit rates between high- and low-utilizing hospitals were not significant (OR=1.21; 95% CI, 0.97-1.51), suggesting that low-utilizing EDs are not discharging children that should have been hospitalized.

“Some variation in care is always to be expected - individual patients and clinicians are different people with different care needs,” Florin told Infectious Diseases in Children. “That said, our work demonstrates substantial variation in care, even after statistically adjusting for individual patient and hospital factors. I believe that such variation is largely due to two factors - first, there is insufficient high-quality evidence to guide clinical practice and, more importantly, in my opinion, when strong evidence does exist, it is not effectively disseminated and implemented. We need to understand the reasons and motivations behind clinical decision making, work to find efficient and effective ways to translate high-quality evidence and national guidelines into various practice settings, and then find ways to measure how well we are following such evidence, thus minimizing unnecessary utilization.”

Todd A. Florin, MD, MSCE, FAAP. can be reached at Cincinnati Children’s Hospital Medical Center, Division of Emergency Medicine, 3333 Burnet Avenue, ML 2008, Cincinnati, OH 45229; emaiL: todd.florin@cchmc.org.

Disclosure: The study was funded in part by a grant from The Center for Pediatric Clinical Effectiveness at The Children’s Hospital of Philadelphia.