Identifying Potentially Unnecessary Hospitalizations in Children With Pneumonia

Author:

Ramgopal Sriram1,Lorenz Douglas2,Ambroggio Lilliam34,Navanandan Nidhya3,Cotter Jillian M.4,Florin Todd A.1

Affiliation:

1. aDivision of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois

2. bDepartment of Bioinformatics and Biostatistics, University of Louisville, Louisville, Kentucky

3. cSection of Pediatric Emergency Medicine and

4. dSection of Pediatric Hospital Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, Colorado

Abstract

OBJECTIVE To characterize the outcomes of children with community acquired pneumonia (CAP) across 41 United States hospitals and evaluate factors associated with potentially unnecessary admissions. METHODS We performed a cross-sectional study of patients with CAP from 41 United States pediatric hospitals and evaluated clinical outcomes using a composite ordinal severity outcome: mild-discharged (discharged from the emergency department), mild-admitted (hospitalized without other interventions), moderate (provision of intravenous fluids, supplemental oxygen, broadening of antibiotics, complicated pneumonia, and presumed sepsis) or severe (ICU, positive-pressure ventilation, vasoactive infusion, chest drainage, extracorporeal membrane oxygenation, severe sepsis, or death). Our primary outcome was potentially unnecessary admissions (ie, mild-admitted). Among mild-discharged and mild-admitted patients, we constructed a generalized linear mixed model for mild-admitted severity and assessed the role of fixed (demographics and clinical testing) and random effects (institution) on this outcome. RESULTS Of 125 180 children, 68.3% were classified as mild-discharged, 6.6% as mild-admitted, 20.6% as moderate and 4.5% as severe. Among admitted patients (n = 39 692), 8321 (21%) were in the mild-admitted group, with substantial variability in this group across hospitals (median 19.1%, interquartile range 12.8%–28.4%). In generalized linear mixed models comparing mild-admitted and mild-discharge severity groups, hospital had the greatest contribution to model variability compared to all other variables. CONCLUSIONS One in 5 hospitalized children with CAP do not receive significant interventions. Among patients with mild disease, institutional variation is the most important contributor to predict potentially unnecessary admissions. Improved prognostic tools are needed to reduce potentially unnecessary hospitalization of children with CAP.

Publisher

American Academy of Pediatrics (AAP)

Subject

Pediatrics,General Medicine,Pediatrics, Perinatology and Child Health

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