0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

Auditing Practice Style Variation in Pediatric Inpatient Asthma Care

Jeffrey H. Silber, MD, PhD1,2,3,4,5; Paul R. Rosenbaum, PhD5,6; Wei Wang, PhD1; Justin M. Ludwig, MA1; Shawna Calhoun, MPH1; James P. Guevara, MD, MPH5,7; Joseph J. Zorc, MD, MSCE2,8; Ashley Zeigler, BA1; Orit Even-Shoshan, MS1
[+] Author Affiliations
1Center for Outcomes Research, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
2Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
3Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
4Department of Health Care Management, Wharton School, University of Pennsylvania, Philadelphia
5Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
6Department of Statistics, Wharton School, University of Pennsylvania, Philadelphia
7Division of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
8Division of Emergency Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
JAMA Pediatr. 2016;170(9):878-886. doi:10.1001/jamapediatrics.2016.0911.
Text Size: A A A
Published online

Importance  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.

Objective  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.

Exposure  Treatment at each PHIS hospital.

Main Outcomess and Measures  Cost, length of stay, and intensive care unit (ICU) utilization.

Results  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).

Conclusions and Relevance  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.

Figures in this Article

Figures

Place holder to copy figure label and caption
Figure 1.
A Description of Template Matching

Each geometric shape represents a different type of patient (eg, patient with asthma admitted with different physiologic severity), and the varying sizes of each shape represent different characteristics of that patient type (eg, different ages). A template is formed from the national sample and each hospital is matched to the template using a 1:1, 2:1, or 3:1 ratio, depending on the available sample size at that hospital.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Cost by Length of Stay (LOS) by Intensive Care Unit (ICU) Utilization

The Spearman correlation coefficient r between median cost (A) and trimmed LOS (B) was highly significant (r = 0.57; P < .001), the correlation between ICU utilization (C) and trimmed LOS was significant (r = 0.41, P = .01), and the correlation between median cost and ICU utilization was not significant (r = 0.03, P = .87). The straight solid lines within the scatterplots were constructed using robust linear model m-estimation.37,38,40

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
In-Hospital Cost by Patient Risk Level

The x-axis of each graph represents the risk, estimated by predicted length of stay, for each template patient strata. The y-axis represents the difference in cost (focal  minus control) inside each matched pair. A point falling on the horizontal line at 0 represents no difference in cost between the 2 patients in the matched pair, and a point falling below the line suggests a lower cost for the focal vs control patient. The solid lines represent the locally weighted scatterplot smoothing (LOWESS) line.41 LOWESS 95% CI bands (shaded areas) for the central tendency line were produced using the bootstrap method. A box plot at the bottom of each graph denotes the 5%, 25%, 50%, 75%, and 95% values of predicted risk over all strata. Each graph illustrates an individual hospital.

Graphic Jump Location

Tables

References

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

799 Views
0 Citations
×

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles
Jobs
JAMAevidence.com

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Quick Reference

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Quick Reference

brightcove.createExperiences();