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Age-based EMR tool improves diagnosis in pediatric acute liver failure

Incorporation of age-based diagnostic recommendations into electronic medical records for children with acute liver failure reduced indeterminant diagnoses and may improve outcomes by reducing liver transplantation rates without an increase in mortality, according to a recently published study.

Robert Squires

“For patients presenting with acute liver failure, having a diagnostic tool that is age-specific will enhance the diagnostic sensitivity,” Robert H. Squires, MD, from the Children’s Hospital of Pittsburgh at the University of Pittsburgh Medical Center, told Healio Gastroenterology and Liver Disease. “It seems to have increased the frequency of testing for specific diagnoses and decreased the indeterminant rate.”

Squires and colleagues conducted an observational study in three phases: the first phase followed pediatric patients with acute liver failure for 21 days after hospital admission and the second phase followed surviving children from 21 days to 1 year. In phase 3, the researchers implemented the diagnostic tool and compared follow-up results with the first two phases.

Age-specific diagnoses reported in phase 1 and phase 2 determined the age-specific diagnostic testing recommendations for phase 3.

Results of the phase 3 study showed that patients aged younger than 90 days had an increase in diagnostic testing for herpes simplex virus (P = .006), enterovirus (P < .0001), lactate (P = .03) and pyruvate (P = .02). Children aged 90 days or older had an increase in diagnostic testing for all three autoantibodies, enterovirus, serum amino acids, acylcarnitine profile, lactate, pyruvate, and acetaminophen (P < .0001); and ferritin (P = .0001), antinuclear antibody (P = .0004) and HSV (P = .006).

The overall percentage of patients with an indeterminant diagnosis decreased significantly between combined phase 1 and 2 results and phase 3 (48% vs. 30.8%; P = .0003) and in each age group, especially the oldest age group (44.2% vs. 24.2%; P = .004).

The cumulative incidence rate for liver transplantation at 21 days was significantly lower in phase 3 (20.2%; P = .03) compared with phase 1 (34.6%) and phase 2 (31.9%), which remained significant after adjusting for patient age and clinical center (HR = 0.6; P = .02).

In contrast, the cumulative incidence rate for mortality did not increase significantly between phase 1 (17.9%), phase 2 (11.9%) and phase 3 (11.3%).

“Traditional approaches to differential diagnoses often include prioritization of certain diagnostic tests and then seeing if they’re positive or negative before going to second and third tier diagnostic testing, but this can happen over time,” Squires said. “In a patient with acute liver failure, their outcome can be determined within days, so there really isn’t the time to prioritize who should get these diagnostic tests today instead of next week.” – by Talitha Bennett

Disclosure: The authors report no relevant financial disclosures.