Establishment of achievable benchmarks of care in the neurodiagnostic evaluation of simple febrile seizures

Abstract

Background: Current guidelines recommend against neurodiagnostic testing for the evaluation of simple febrile seizures.

Objectives: (1) Assess overall and institutional rates of neurodiagnostic testing and (2) establish achievable benchmarks of care (ABCs) for children evaluated for simple febrile seizures at children's hospitals.

Design, setting, and participants: Cross-sectional study of children 6 months to 5 years evaluated in the emergency department (ED) 2016-2019 with simple febrile seizures at 38 children's hospitals in Pediatric Health Information System database. We excluded children with epilepsy, complex febrile seizures, complex chronic conditions, and intensive care.

Outcome measures: Proportions of children who received neuroimaging, electroencephalogram (EEG), or lumbar puncture (LP) and rates of hospitalization for study cohort and individual hospitals. Hospital-specific outcomes were adjusted for patient demographics and severity of illness. We utilized hospital-specific values for each measure to calculate ABCs.

Results: We identified 51,015 encounters. Among the study cohort 821 (1.6%) children had neuroimaging, 554 (1.1%) EEG, 314 (0.6%) LP, and 2023 (4.0%) were hospitalized. Neurodiagnostic testing rates varied across hospitals: neuroimaging 0.4%-6.7%, EEG 0%-8.2%, LP 0%-12.7% in patients <1-year old and 0%-3.1% in patients ≥1 year. Hospitalization rate ranged from 0%-14.5%. Measured outcomes were higher among hospitalized versus ED-only patients: neuroimaging 15.3% versus 1.0%, EEG% 24.7 versus 0.1% (p < .001). Calculated ABCs were 0.6% for neuroimaging, 0.1% EEG, 0% LP, and 1.0% hospitalization.

Conclusions: Rates of neurodiagnostic testing and hospitalization for simple febrile seizures were low but varied across hospitals. Calculated ABCs were 0%-1% for all measures, demonstrating that adherence to current guidelines is attainable.

FIGURE B1

Consolidated Standards of Reporting Trials (CONSORT) diagram of included and excluded study patients. CCC, complex chronic condition; ICU, intensive care unit; LOS, length of stay

FIGURE E1

Heat map of rates of neurodiagnostic test use for hospital encounters by individual hospital, arranged by highest (Hospital 1) to lowest (Hospital 38) adjusted admission rate. Colors correspond to levels of use, ranging from red (highest rate) to dark green (lowest rate). NA: Could not calculate % due to 0 value for outcome. ED, emergency department; EEG, electroencephalogram; LP, lumbar puncture

FIGURE F1

Heat map of rates of neurodiagnostic test use for ED only encounters by individual hospital, arranged by highest (Hospital 1) to lowest (Hospital 38) adjusted admission rate. Colors correspond to levels of use, ranging from red (highest rate) to dark green (lowest rate). ED, emergency department; EEG, electroencephalogram; LP, lumbar puncture

FIGURE H1

Association between hospital-level risk-adjusted admission rate after initial ED visit for simple febrile seizure and 30 days all-cause admission rate (top panel) and 30 days ED revisit rate (bottom panel) for patients discharged from ED at initial visit. Admission rate was adjusted for age, gender, race, payor, and HRISK score. ED, emergency department; HRISK, Hospitalization Resource Intensity Scores for Kids

FIGURE 1

Heat map of rates of neurodiagnostic test use for all encounters by individual hospital, arranged by highest (Hospital 1) to lowest (Hospital 38) adjusted admission rate. Colors correspond to levels of use, ranging from red (highest rate) to dark green (lowest rate). ED, emergency department; EEG, electroencephalogram; LP, lumbar puncture

FIGURE 2

Risk-adjusted admission rates for patients with simple febrile seizures, adjusted for age, race, gender, payor, and HRISK score. Upper and lower control limits are displayed for each value. CI, confidence interval; HRISK, Hospitalization Resource Intensity Scores for Kids