Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania2Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia3Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia4Department of Health Care Management, Wharton School, University of Pennsylvania, Philadelphia5Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.
Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia6Department of Statistics, Wharton School, University of Pennsylvania, Philadelphia.
JAMA Pediatr. 2016 Sep 1;170(9):878-86. doi: 10.1001/jamapediatrics.2016.0911.
Asthma is the most prevalent chronic illness among children, remaining a leading cause of pediatric hospitalizations and representing a major financial burden to many health care systems.
To implement a new auditing process examining whether differences in hospital practice style may be associated with potential resource savings or inefficiencies in treating pediatric asthma admissions.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective matched-cohort design study, matched for asthma severity, compared practice patterns for patients admitted to Children's Hospital Association hospitals contributing data to the Pediatric Hospital Information System (PHIS) database. With 3 years of PHIS data on 48 887 children, an asthma template was constructed consisting of representative children hospitalized for asthma between April 1, 2011, and March 31, 2014. The template was matched with either a 1:1, 2:1, or 3:1 ratio at each of 37 tertiary care children's hospitals, depending on available sample size.
Treatment at each PHIS hospital.
Cost, length of stay, and intensive care unit (ICU) utilization.
After matching patients (n = 9100; mean [SD] age, 7.1 [3.6] years; 3418 [37.6%] females) to the template (n = 100, mean [SD] age, 7.2 [3.7] years; 37 [37.0%] females), there was no significant difference in observable patient characteristics at the 37 hospitals meeting the matching criteria. Despite similar characteristics of the patients, we observed large and significant variation in use of the ICUs as well as in length of stay and cost. For the same template-matched populations, comparing utilization between the 12.5th percentile (lower eighth) and 87.5th percentile (upper eighth) of hospitals, median cost varied by 87% ($3157 vs $5912 per patient; P < .001); total hospital length of stay varied by 47% (1.5 vs 2.2 days; P < .001); and ICU utilization was 254% higher (6.5% vs 23.0%; P < .001). Furthermore, the patterns of resource utilization by patient risk differed significantly across hospitals. For example, as patient risk increased one hospital displayed significantly increasing costs compared with their matched controls (comparative cost difference: lowest risk, -34.21%; highest risk, 53.27%; P < .001). In contrast, another hospital displayed significantly decreasing costs relative to their matched controls as patient risk increased (comparative cost difference: lowest risk, -10.12%; highest risk, -16.85%; P = .01).
For children with asthma who had similar characteristics, we observed different hospital resource utilization; some values differed greatly, with important differences by initial patient risk. Through the template matching audit, hospitals and stakeholders can better understand where this excess variation occurs and can help to pinpoint practice styles that should be emulated or avoided.
哮喘是儿童中最常见的慢性病，仍然是导致儿科住院的主要原因，也是许多医疗保健系统的主要经济负担。
实施新的审核流程，以检查医院的实践方式是否存在潜在的资源节约或治疗儿科哮喘入院的效率低下。
设计、设置和参与者：一项回顾性匹配队列设计研究，根据哮喘严重程度进行匹配，比较了向儿科医院协会医院提供数据的儿科医院信息系统（PHIS）数据库的患者的治疗模式。利用 PHIS 数据库中 3 年的 48887 名儿童的数据，为 2011 年 4 月 1 日至 2014 年 3 月 31 日期间住院治疗哮喘的代表性儿童建立了哮喘模板。该模板在 37 家三级儿童医院中的每家医院都以 1:1、2:1 或 3:1 的比例进行匹配，具体取决于可用样本量。
PHIS 医院的治疗。
成本、住院时间和重症监护病房（ICU）使用率。
在将患者（n=9100；平均[SD]年龄为 7.1[3.6]岁；3418[37.6%]为女性）与模板（n=100；平均[SD]年龄为 7.2[3.7]岁；37[37.0%]为女性）匹配后（n=100；平均[SD]年龄为 7.2[3.7]岁；37[37.0%]为女性），符合匹配标准的 37 家医院的患者特征没有显著差异。尽管患者的特征相似，但我们观察到 ICU 以及住院时间和费用的使用存在很大且显著的差异。对于相同的模板匹配人群，比较 12.5 百分位（下 8 分位）和 87.5 百分位（上 8 分位）医院的利用情况，中位数成本差异为 87%（每位患者 3157 美元与 5912 美元；P<.001）；总住院时间差异为 47%（1.5 天与 2.2 天；P<.001）；ICU 利用率高 254%（6.5%与 23.0%；P<.001）。此外，医院之间患者风险的资源利用模式存在显著差异。例如，随着患者风险的增加，一家医院与他们的匹配对照组相比，成本显著增加（比较成本差异：最低风险，-34.21%；最高风险，53.27%；P<.001）。相比之下，另一家医院与他们的匹配对照组相比，随着患者风险的增加，成本显著降低（比较成本差异：最低风险，-10.12%；最高风险，-16.85%；P=.01）。
对于具有相似特征的哮喘儿童，我们观察到不同的医院资源利用情况；一些值差异很大，初始患者风险差异很大。通过模板匹配审核，医院和利益相关者可以更好地了解这种额外差异发生的地方，并有助于确定应该效仿或避免的实践模式。
