国家指南对儿童医院肺炎患儿诊断资源利用的总体及医院层面影响。

Aggregate and hospital-level impact of national guidelines on diagnostic resource utilization for children with pneumonia at children's hospitals.

作者信息

Parikh Kavita, Hall Matt, Blaschke Anne J, Grijalva Carlos G, Brogan Thomas V, Neuman Mark I, Williams Derek J, Gerber Jeffrey S, Hersh Adam L, Shah Samir S

机构信息

Division of Hospitalist Medicine, Department of Pediatrics, Children's National Medical Center and George Washington School of Medicine, Washington, DC.

Children's Hospital Association, Overland Park, Kansas.

出版信息

J Hosp Med. 2016 May;11(5):317-23. doi: 10.1002/jhm.2534. Epub 2016 Jan 13.

DOI:10.1002/jhm.2534

PMID:26762571

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC5103701/

Abstract

BACKGROUND

National guidelines for the management of community-acquired pneumonia (CAP) in children were published in 2011. These guidelines discourage most diagnostic testing for outpatients, as well as repeat testing for hospitalized patients who are improving. We sought to evaluate the temporal trends in diagnostic testing associated with guideline implementation among children with CAP.

METHODS

Children 1 to 18 years old who were discharged with pneumonia after emergency department (ED) evaluation or hospitalization from January 1, 2008 to June 30, 2014 at any of 32 children's hospitals participating in the Pediatric Health Information System were included. We excluded children with complex chronic conditions and those requiring intensive care or who underwent early pleural drainage. We compared use of diagnostic testing (blood culture, complete blood count [CBC], C-reactive protein [CRP], and chest radiography [CXR]) before and after release of the guidelines, and assessed for temporal trends using interrupted time series analysis. We also calculated the cost impact of these changes on diagnostic utilization and evaluated the variability of the guideline's impact across hospitals.

RESULTS

Overall, 220,539 patients were included; 53% were male and the median age was 4 years (interquartile range, 2-7). For patients discharged from the ED with CAP, diagnostic utilization rates for blood culture, CBC, CRP, and CXR were higher after guideline publication compared with expected utilization rates without guidelines. In contrast, initial testing and repeat testing among patients hospitalized with CAP was lower after guideline publication. There were modest reductions in estimated costs associated with these changes. However, wide variability was observed in the impact of the guidelines across hospitals.

CONCLUSIONS

Publication of national pneumonia guidelines in 2011 was associated with modest changes in diagnostic testing for children with CAP. However, the changes varied across hospitals, and the financial impact was modest. Local implementation efforts are warranted to ensure widespread guideline adherence. Journal of Hospital Medicine 2016;11:317-323. © 2016 Society of Hospital Medicine.

摘要

背景

儿童社区获得性肺炎（CAP）管理的国家指南于2011年发布。这些指南不鼓励对门诊患者进行大多数诊断检测，也不鼓励对病情正在改善的住院患者进行重复检测。我们试图评估与CAP儿童指南实施相关的诊断检测的时间趋势。

方法

纳入2008年1月1日至2014年6月30日期间在参与儿科健康信息系统的32家儿童医院中的任何一家因肺炎经急诊科（ED）评估或住院后出院的1至18岁儿童。我们排除了患有复杂慢性病的儿童以及需要重症监护或接受早期胸腔引流的儿童。我们比较了指南发布前后诊断检测（血培养、全血细胞计数[CBC]、C反应蛋白[CRP]和胸部X线摄影[CXR]）的使用情况，并使用中断时间序列分析评估时间趋势。我们还计算了这些变化对诊断利用的成本影响，并评估了指南影响在各医院之间的变异性。

结果

总体而言，纳入了220,539名患者；53%为男性，中位年龄为4岁（四分位间距，2 - 7岁）。对于因CAP从ED出院的患者，与无指南时的预期利用率相比，指南发布后血培养、CBC、CRP和CXR的诊断利用率更高。相比之下，指南发布后，因CAP住院患者的初始检测和重复检测较低。这些变化导致估计成本有适度降低。然而，各医院之间指南的影响存在很大差异。