Pediatric CAP: Hospitals Vary in Diagnostic Testing, not Outcomes

Emergency departments (EDs) that use more diagnostic testing for pediatric community-acquired pneumonia (CAP) have more hospitalizations for the indication, but not significantly fewer revisits to the ED compared with EDs that do less diagnostic testing, according to a study published online July 22 in Pediatrics.

Todd A. Florin, MD, from Cincinnati Children's Hospital Medical Center in Ohio, and colleagues used a multicenter, retrospective cohort design to analyze 100,615 ED visits for pneumonia in children aged 2 months to 18 years. They used data from the Pediatric Health Information System, a database of 43 not-for-profit tertiary care pediatric hospitals in the United States. The researchers excluded patients with aspiration pneumonia, trauma, recent hospitalization, perinatal infection, or complex chronic medical conditions.

The primary outcomes for their study included diagnostic testing, hospitalization, and re-visits to the ED within 3 days of the initial visit. Diagnostic testing typically consisted of complete blood count (median adjusted proportion of patients receiving the test, 28.7%), blood culture (27.9%), and chest X-ray (75.7%). The investigators adjusted the ED test use for age, sex, race/ethnicity, season of presentation, year of presentation, and insurance status.

The hospitals varied widely in use of diagnostic testing to evaluate CAP. Multivariate mixed-effects logistic regression revealed that hospitals that did more rigorous diagnostic work-ups were more likely to hospitalize patients with pneumonia (odds ratio [OR], 1.86; 95% confidence interval [CI], 1.17 - 2.94; P = .008). However, ED revisits were not more likely in the hospitals with more rigorous diagnostic testing (OR, 1.21; 95% CI, 0.97 - 1.51; P = .09).

The researchers conclude that reducing diagnostic testing for CAP may be an opportunity to improve efficiency of care without negatively affecting outcomes." 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," they write.

Limitations of the study include its application only to children's hospitals, lack of information on admission standards or indications for diagnostic tests, and lack of evaluation of the test results.

Two other articles in this issue of Pediatrics examine variation in cost of care for common conditions. In an editorial responding to all 3 papers, Mark I. Neuman, MD, MPH, and Vincent W. Chiang, MD, from Boston Children's Hospital in Massachusetts, write that the trio of studies "present an opportunity for physicians and hospitals to evaluate the care they provide to reduce unnecessary, or low-value, diagnostic testing and to improve patient care." The editorialists call for a universally accepted standard of care for evaluating pneumonia.

The researchers and editorialists have disclosed no relevant financial relationships.

Pediatrics. Published online July 22, 2013. Abstract

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