Variation in Chest Radiograph Use for Children With Complicated Pneumonia Requiring Thoracostomy
Michelle Polich1,2, Melissa Cameron1,2, Christiane Lenzen1,2
1Division of Pediatric Hospital Medicine, Rady Children's Health San Diego, San Diego, California.
Insights
Routine chest radiographs (CXRs) vary widely in hospitals for pneumonia patients needing chest tubes. High-CXR usage hospitals had increased costs, but no differences in complications or length of stay were observed.
Area of Science:
- Pediatric critical care
- Thoracic surgery
- Radiology
Background:
- Complicated pneumonia in children often requires chest tubes for management.
- Chest radiographs (CXRs) are frequently used to monitor these patients.
- Significant variation in CXR ordering practices among hospitals is suspected.
Purpose of the Study:
- To evaluate the variation in CXR ordering frequency for pediatric patients with complicated pneumonia requiring chest tubes.
- To assess the association between CXR ordering rates and patient outcomes, including complications, length of stay, costs, and readmissions.
Main Methods:
- Utilized the Pediatric Health Information System (PHIS) database for children aged 6 months to 18 years with complicated pneumonia undergoing thoracostomy (July 2019-June 2023).
- Calculated the proportion of daily CXRs ordered per encounter, adjusting for various factors.
- Hospitals were stratified into quartiles based on their median daily CXR ordering proportion to compare adjusted outcomes.
Main Results:
- A total of 1817 children were included; the median daily CXR proportion across all encounters was 0.68.
- Hospital-level median adjusted daily CXR proportions ranged from 0.30 to 0.91.
- No significant differences were found in pneumothorax, repeat thoracostomy, post-thoracostomy days, length of stay, or 30-day readmissions across CXR usage quartiles.
- Hospitals with higher CXR usage demonstrated significantly higher associated costs.
Conclusions:
- Substantial variation exists in the frequency of ordering chest radiographs for pediatric patients with complicated pneumonia requiring chest tubes.
- Higher rates of CXR ordering were associated with increased hospital costs without improving key patient outcomes.
- Further research is needed to identify clinical factors influencing chest tube complications and to guide optimal CXR ordering strategies.
Background:
Routine chest radiographs (CXRs) are often used to monitor patients with complicated pneumonia requiring chest tubes. We aim to evaluate the following: (1) variation in CXR ordering; and (2) outcomes such as tube-related complications, length of stay (LOS), costs, and 30-day readmissions among hospitals with differing rates of CXR orders.
Methods:
Using Pediatric Health Information System (PHIS) data, this study examined children aged 6 months to 18 years with complicated pneumonia receiving thoracostomy between July 2019 and June 2023. Unadjusted and adjusted proportions of number of eligible days that a CXR was obtained following thoracostomy for each encounter were calculated. At the hospital level, the median adjusted proportion of daily CXRs ordered per encounter was calculated. Hospitals were grouped into quartiles by hospital median daily CXR proportions, and adjusted outcomes were compared.
Results:
Of 1817 children, 44.1% were female, and the median age was 5 years. Adjusted median (IQR) daily CXR proportion for all encounters was 0.68 (0.55, 0.81). At the hospital level, the median adjusted proportion of daily CXRs ordered ranged from 0.30 to 0.91, with 20% of hospital IQRs falling outside of the IQR for all encounters. There were no differences in postprocedural pneumothorax, repeated thoracostomy, log post-thoracostomy days, log LOS, or 30-day readmissions across quartiles; however, there were higher log costs among high-use compared with low-use hospitals.
Conclusions:
Variation exists in CXR ordering among hospitals for patients with complicated pneumonia requiring chest tubes. There were no differences in most outcomes, but high-use hospitals incurred higher costs. Future studies should address clinical factors associated with chest tube complications to guide targeted approaches to CXR ordering.
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