Variation in resource utilization for the management of uncomplicated community-acquired pneumonia across community and children's hospitals

Abstract

Objective: To describe patterns of diagnostic testing and antibiotic management of uncomplicated pneumonia in general community hospitals and children's hospitals within hospitals and to determine the association between diagnostic testing and length of hospital stay.

Study design: We conducted a retrospective cohort study of children 1-17 years of age hospitalized with the diagnosis of pneumonia from 2007 to 2010 to hospitals contributing data to Perspective Database Warehouse, assessing patterns of diagnostic testing and antibiotic management. We constructed logistic regression models of log-transformed length of stay (LOS) and grouped treatment models to ascertain whether performance of blood cultures and viral respiratory testing were associated with LOS.

Results: A total of 17 299 pneumonia cases occurred at 125 hospitals, with considerable variability in pneumonia management. Only 40 (0.2%) received ampicillin/penicillin G alone or in combination with other antibiotics, and 1318 (7.4%) received macrolide monotherapy as initial antibiotic management. Performance of blood culture and testing for respiratory viruses was associated with a statistically significant longer LOS, but these differences did not persist in grouped treatment models.

Conclusions: We observed greater rates of diagnostic testing in this cohort of structurally diverse hospitals than previously reported at freestanding children's hospitals, with extremely low rates of narrow-spectrum antibiotic use. Tailored antibiotic stewardship initiatives at these hospitals are needed to achieve adherence to national guideline recommendations.

Figure 1

Box plot illustrating hospital-level variation in rates of diagnostic testing.** Figure 1 footnote: * significantly different between children's hospitals and general community hospitals (p<0.01) Figure 1 footnote: ** center box illustrates median and interquartile range; whiskers illustrate range excluding outliers; dots illustrate outliers.

Figure 2

Boxplot illustrating hospital-level variation in initial antibiotic management** Figure 2 footnote: * significantly different between children's hospitals and general community hospitals (p<0.01) Figure 2 footnote: ** center box illustrates median and interquartile range; whiskers illustrate range excluding outliers; dots illustrate outliers.