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Diagnostic testing for evaluation of brief resolved unexplained events
Manoj K Mittal1, Joel S Tieder2, Kathryn Westphal3
1Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Insights
Diagnostic testing for brief resolved unexplained events (BRUEs) in infants has low yield. This multicenter study found that tests rarely contribute to a confirmatory diagnosis, even in higher-risk cases.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Diagnostics
- Infant Health
Background:
- Brief Resolved Unexplained Events (BRUEs) are a clinical concern in infants.
- Previous studies suggested limited utility of diagnostic testing for BRUEs.
- A need exists to evaluate diagnostic test yield in a larger, multicenter cohort.
Purpose of the Study:
- To determine the diagnostic yield of testing in infants presenting with BRUE.
- To assess the contribution of laboratory, imaging, and ancillary tests to final diagnoses.
- To evaluate testing utility in infants meeting American Academy of Pediatrics (AAP) higher-risk criteria.
Main Methods:
- Retrospective analysis of a multicenter cohort of infants < 1 year old.
- Inclusion criteria based on validated administrative data algorithm for BRUEs.
- Chart review to confirm diagnoses, risk criteria, and test contribution.
Main Results:
- Of 2036 infants, 45.3% received an explanatory diagnosis.
- Diagnostic tests supported the final diagnosis in only 3.2% of patients.
- Laboratory and imaging tests contributed to diagnoses in 1.1% and 1.5% of cases, respectively.
Conclusions:
- Diagnostic testing for BRUEs, including higher-risk infants, has low diagnostic yield.
- Current testing strategies rarely explain BRUEs.
- Further research should focus on specific, at-risk infant populations.
Background:
Since the publication of the American Academy of Pediatrics (AAP) clinical practice guideline for brief resolved unexplained events (BRUEs), a few small, single-center studies have suggested low yield of diagnostic testing in infants presenting with such an event. We conducted this large retrospective multicenter study to determine the role of diagnostic testing in leading to a confirmatory diagnosis in BRUE patients.
Methods:
Secondary analysis from a large multicenter cohort derived from 15 hospitals participating in the BRUE Quality Improvement and Research Collaborative. The study subjects were infants < 1 year of age presenting with a BRUE to the emergency departments (EDs) of these hospitals between October 1, 2015, and September 30, 2018. Potential BRUE cases were identified using a validated algorithm that relies on administrative data. Chart review was conducted to confirm study inclusion/exclusion, AAP risk criteria, final diagnosis, and contribution of test results. Findings were stratified by ED or hospital discharge and AAP risk criteria. For each patient, we identified whether any diagnostic test contributed to the final diagnosis. We distinguished true (contributory) results from false-positive results.
Results:
Of 2036 patients meeting study criteria, 63.2% were hospitalized, 87.1% qualified as AAP higher risk, and 45.3% received an explanatory diagnosis. Overall, a laboratory test, imaging, or an ancillary test supported the final diagnosis in 3.2% (65/2036, 95% confidence interval [CI] 2.7%-4.4%) of patients. Out of 5163 diagnostic tests overall, 1.1% (33/2897, 95% CI 0.8%-1.5%) laboratory tests and 1.5% (33/2266, 95% CI 1.0%-1.9%) of imaging and ancillary studies contributed to a diagnosis. Although 861 electrocardiograms were performed, no new cardiac diagnoses were identified during the index visit.
Conclusions:
Diagnostic testing to explain BRUE including for those with AAP higher risk criteria is low yield and rarely contributes to an explanation. Future research is needed to evaluate the role of testing in more specific, at-risk populations.
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