Variation in Diagnostic Test Use and Associated Outcomes in Staphylococcal Scalded Skin Syndrome at Children's Hospitals

Abstract

Objectives: The incidence of staphylococcal scalded skin syndrome (SSSS) is rising, but current practice variation in diagnostic test use is not well described. Our aim was to describe the variation in diagnostic test use in children hospitalized with SSSS and to determine associations with patient outcomes.

Methods: We performed a retrospective (2011-2016) cohort study of children aged 0 to 18 years from 35 children's hospitals in the Pediatric Health Information System database. Tests included blood culture, complete blood count, erythrocyte sedimentation rate, C-reactive protein level, serum chemistries, and group A streptococcal testing. K-means clustering was used to stratify hospitals into groups of high (cluster 1) and low (cluster 2) test use. Associations between clusters and patient outcomes (length of stay, cost, readmissions, and emergency department revisits) were assessed with generalized linear mixed-effects modeling.

Results: We included 1259 hospitalized children with SSSS; 84% were ≤4 years old. Substantial interhospital variation was seen in diagnostic testing. Blood culture was the most commonly obtained test (range 62%-100%), with the most variation seen in inflammatory markers (14%-100%). Between hospital clusters 1 and 2, respectively, there was no significant difference in adjusted length of stay (2.6 vs 2.5 days; P = .235), cost ($4752 vs $4453; P = .591), same-cause 7-day readmission rate (0.8% vs 0.4%; P = .349), or emergency department revisit rates (0.1% vs 0.6%; P = .148).

Conclusions: For children hospitalized with SSSS, lower use of diagnostic tests was not associated with changes in outcomes. Hospitals with high diagnostic test use may be able to reduce testing without adversely affecting patient outcomes.

FIGURE 1

Flowchart of study population.

FIGURE 2

Comparison of distribution of diagnostic testing for hospital clusters 1 and 2. Boxes extend to the 25th and 75th percentiles. Lines indicate median testing rates. Whiskers represent 1.5 × IQR from the edge of the box.

FIGURE 3

Heat map of hospital-specific use of diagnostic testing. Numbers indicate the percentage of children at each hospital that received each test. Hospitals are sorted by highest to lowest mean testing rate across the 5 tests with the cluster number indicated. Shading corresponds to use quartile, with darker shading indicating higher use.