Identifying Pediatric Community-Acquired Pneumonia Hospitalizations Accuracy of Administrative Billing Codes
Division of Hospital Medicine, The Monroe Carell Jr Children's Hospital at Vanderbilt and Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee.
07/2013; 167(9). DOI: 10.1001/jamapediatrics.2013.186
Community-acquired pneumonia (CAP) remains one of the most common indications for pediatric hospitalization in the United States, and it is frequently the focus of research and quality studies. Use of administrative data is increasingly common for these purposes, although proper validation is required to ensure valid study conclusions.Objective
To validate administrative billing data for hospitalizations owing to childhood CAP.Design and Setting
Case-control study of 4 tertiary care, freestanding children’s hospitals in the United States.Participants
A total of 998 medical records of a 25% random sample of 3646 children discharged in 2010 with at least 1 International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code representing possible pneumonia were reviewed. Discharges (matched on date of admission) without a pneumonia-related discharge code were also examined to identify potential missed pneumonia cases. Two reference standards, based on provider diagnosis alone (provider confirmed) or in combination with consistent clinical and radiographic evidence of pneumonia (definite), were used to identify CAP.Exposure
Twelve ICD-9-CM–based coding strategies, each using a combination of primary or secondary codes representing pneumonia or pneumonia-related complications. Six algorithms excluded children with complex chronic conditions.Main Outcomes and Measures
Sensitivity, specificity, and negative and positive predictive values (NPV and PPV, respectively) of the 12 identification strategies.Results
For provider-confirmed CAP (n = 680), sensitivity ranged from 60.7% to 99.7%; specificity, 75.7% to 96.4%; PPV, 67.9% to 89.6%; and NPV, 82.6% to 99.8%. For definite CAP (n = 547), sensitivity ranged from 65.6% to 99.6%; specificity, 68.7% to 93.0%; PPV, 54.6% to 77.9%; and NPV, 87.8% to 99.8%. Unrestricted use of the pneumonia-related codes was inaccurate, although several strategies improved specificity to more than 90% with a variable effect on sensitivity. Excluding children with complex chronic conditions demonstrated the most favorable performance characteristics. Performance of the algorithms was similar across institutions.Conclusions and Relevance
Administrative data are valuable for studying pediatric CAP hospitalizations. The strategies presented here will aid in the accurate identification of relevant and comparable patient populations for research and performance improvement studies.
Available from: Thomas Brogan
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The 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America community-acquired pneumonia (CAP) guideline recommends narrow-spectrum antimicrobial therapy for most children hospitalized with CAP. However, few studies have assessed the effectiveness of this strategy.
Using data from 43 children's hospitals, we conducted a retrospective cohort study to compare outcomes and resource utilization among children hospitalized with CAP between 2005 and 2011 receiving either parenteral ampicillin/penicillin (narrow spectrum) or ceftriaxone/cefotaxime (broad spectrum). Children with complex chronic conditions, interhospital transfers, recent hospitalization, or the occurrence of any of the following during the first 2 calendar days of hospitalization were excluded: pleural drainage procedure, admission to intensive care, mechanical ventilation, death, or hospital discharge.
Overall, 13,954 children received broad-spectrum therapy (89.7%) and 1610 received narrow-spectrum therapy (10.3%). The median length of stay was 3 days (interquartile range 3-4) in the broad- and narrow-spectrum therapy groups (adjusted difference 0.12 days, 95% confidence interval [CI]: -0.02 to 0.26). One hundred fifty-six children (1.1%) receiving broad-spectrum therapy and 13 children (0.8%) receiving narrow-spectrum therapy were admitted to intensive care (adjusted odds ratio 0.85, 95% CI: 0.27 to 2.73). Readmission occurred for 321 children (2.3%) receiving broad-spectrum therapy and 39 children (2.4%) receiving narrow-spectrum therapy (adjusted odds ratio 0.85, 95% CI: 0.45 to 1.63). Median costs for the hospitalization were $3992 and $4375 (adjusted difference -$14.4, 95% CI: -177.1 to 148.3).
Clinical outcomes and costs for children hospitalized with CAP are not different when treatment is with narrow- compared with broad-spectrum therapy.
Available from: Matthew Hall
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ABSTRACT: Background and objective:
Narrow-spectrum antibiotics are recommended as the first-line agent for children hospitalized with community-acquired pneumonia (CAP). There is little scientific evidence to support that this consensus-based recommendation is as effective as the more commonly used broad-spectrum antibiotics. The objective was to compare the effectiveness of empiric treatment with narrow-spectrum therapy versus broad-spectrum therapy for children hospitalized with uncomplicated CAP.
This multicenter retrospective cohort study using medical records included children aged 2 months to 18 years at 4 children's hospitals in 2010 with a discharge diagnosis of CAP. Patients receiving either narrow-spectrum or broad-spectrum therapy in the first 2 days of hospitalization were eligible. Patients were matched by using propensity scores that determined each patient's likelihood of receiving empiric narrow or broad coverage. A multivariate logistic regression analysis evaluated the relationship between antibiotic and hospital length of stay (LOS), 7-day readmission, standardized daily costs, duration of fever, and duration of supplemental oxygen.
Among 492 patients, 52% were empirically treated with a narrow-spectrum agent and 48% with a broad-spectrum agent. In the adjusted analysis, the narrow-spectrum group had a 10-hour shorter LOS (P = .04). There was no significant difference in duration of oxygen, duration of fever, or readmission. When modeled for LOS, there was no difference in average daily standardized cost (P = .62) or average daily standardized pharmacy cost (P = .26).
Compared with broad-spectrum agents, narrow-spectrum antibiotic coverage is associated with similar outcomes. Our findings support national consensus recommendations for the use of narrow-spectrum antibiotics in children hospitalized with CAP.
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ABSTRACT: Recently published practice guidelines continue to reflect uncertainty about the comparative effectiveness of various treatments for empyema in children. We describe treatment trends and outcomes in pediatric empyema using the most current nationally representative data.
Using survey methods and Kids' Inpatient Databases from 1997 to 2009, we evaluated hospital stays in children ages 0-18 years. We used 2009 data to compare transfer-out rates and lengths of stay (LOS) across various types of treatment, after adjusting for patient and hospital factors.
From 1997 to 2009, empyema discharges steadily increased from 3.1 to 6.0 per 100,000 children (P < .001 for trend) and, also, were increasingly likely (P<0.01) to be coded for: (1) at least 1 pleural drainage procedure (76.4% to 83.2%), (2) multiple drainage procedures (36.0% to 41.6%), and (3) home health care (8.7% to 15.0%). By 2009, video-assisted thoracoscopic surgery was more commonly coded than chest tube drainage and was associated with a lower transfer-out rate (0.6% vs. 10.1%, adjusted P < .001) but no reduction in mean LOS (11.2 vs. 13.4 days, adjusted incidence rate ratio 0.95 [95% confidence interval: 0.88-1.04]) for children neither admitted nor discharged by transfer.
U.S. hospital stays for empyema in children not only continued to increase through 2009 but were also characterized by more intense procedural management. Outcomes results in this population-based study are consistent with practice guidelines and recommendations that recently endorsed chest tube drainage as an acceptable first treatment option for most children with empyema.
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