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Study found no consensus for tests used to diagnose CAP
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Diagnosis and treatment of community-acquired pneumonia varies widely across children’s hospitals, according to recently published study results.
Thomas V. Brogan, MD, of the division of critical care at Seattle Children’s Hospital, and colleagues evaluated the differences in the use of health care resources in 21,213 patients aged 1 to 18 years with community-acquired pneumonia (CAP) between July 2005 and June 2010. The team examined data from 29 children’s hospitals submitted to the Pediatric Hospital Information System. The researchers ranked care based on eight diagnostic tests and used length of hospital stay, revisit to the ED or readmission to the hospital within 2 weeks of discharge as primary outcomes.
Brogan and colleagues reported a “wide variety” of lab testing and antibiotic use, with cephalosporins being the most commonly prescribed medicine. There was also a variety in length of hospital stay. The researchers said a link between increased diagnostic testing and a longer length of hospital stay was noted and requires further study.
The overall median length of stay was 2 days. Brogan and colleagues also reported that an early discharge did not increase the chance of readmission within 2 weeks.
“The absence of established guidelines during the study years may have contributed to this wide variability in testing, suggesting an important target for influencing both the efficiency and quality of pediatric health care,” the researchers wrote. “Guidelines of care that promote certain laboratory studies may need to be evaluated in light of these findings.”
Disclosure: Dr. Brogan reports no relevant financial disclosures.
Perspective
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John S. Bradley, MD
The manuscript by Brogan, Shah and colleagues on the variability in processes of care for children with community-acquired pneumonia admitted to pediatric hospitals in the Pediatric Hospital Information System collaboration carries an important message for management of these children. Increasingly, we wish that processes of care (eg, CBC, chest X-ray, ESR, blood culture) be based on evidence that can prove that following these processes will improve outcomes for children, our ultimate goal. To tell an incoming pediatric intern that he/she needs to get all these tests for each child admitted with pneumonia, just because “that’s how we’ve always done things at our hospital” now should be backed up with the data to show that each and every test actually does help the child. Useless or misleading tests may actually prevent children from achieving the best outcomes. This manuscript does a superb job of documenting the rather dramatic variability between institutions.
There are issues in analyzing data that are based primarily on billing codes rather than chart reviews that the authors freely acknowledge. However, it is unlikely that anyone is going to review the 21,213 hospital charts that were the subject of this manuscript in order to get patient-level data, like “what pathogen was documented to cause pneumonia?” The fact that the youngest children were least likely to be readmitted may have been related to the fact that they had viral disease that self-resolved, in contrast to complicated bacterial pneumonia that might be a more frequent occurrence in school-aged children. Or there may be many other plausible explanations. In fact, the authors’ statistical associations are simply elegant descriptive associations, but don’t provide us with reasons for the associations. They pose questions that stimulate further investigation. For example, why was a longer length-of-stay associated with fewer 14 day revisits to the emergency department?
Sadly, we don’t have a great deal of high quality data on the impact of processes on the outcomes for pneumonia. New guidelines for pediatric CAP (Clin Infect Dis. 2011;53:e25-76) with Dr. Shah (senior author on this manuscript) as one of the primary authors, exhaustively documents the need for better data.
The authors have provided us an invaluable service by documenting that we need to do better in caring for children with CAP.
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