Identifying Potentially Unnecessary Hospitalizations in Children With Pneumonia

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.

FIGURE 1

Flow diagram of study cohort.

FIGURE 2

Institutional variability of disease severity classification among 41 included hospitals. Hospitals are ordered on the basis of the proportion of patients meeting “mild-admitted” severity criteria.

FIGURE 3

Relative importance of variables in random effects models (assessed by the χ² test for fixed and random effects) which incorporate (A) individual tests, (B) a dichotomous variable of “any” test, and (C) an integer value of the number of effects among the cohort of patients with mild-admitted and mild-discharged disease severity. χ²: Relative importance of variables in mixed effects logistic regression models, as measured by χ² test statistics. The models include as fixed effects either binary indicators for each test (“individual test” model), a binary variable indicating administration of any test (“any test” model), or the number of tests administered (“number of tests” model). FE, fixed effect; RE, random effect.