Auditing Practice Style Variation in Pediatric Inpatient Asthma Care
Authors: Jeffrey H. Silber, Paul R. Rosenbaum, Wei Wang, Justin M. Ludwig, Shawna Calhoun, James P. Guevara, Joseph J. Zorc, Ashley Zeigler, Orit Even-Shoshan
Journal: JAMA Pediatrics (2016)

<h3>Importance</h3> 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. <h3>Objective</h3> 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. <h3>Design, Setting, and Participants</h3> 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. <h3>Exposure</h3> Treatment at each PHIS hospital. <h3>Main Outcomess and Measures</h3> Cost, length of stay, and intensive care unit (ICU) utilization. <h3>Results</h3> 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;<i>P</i> &lt; .001); total hospital length of stay varied by 47% (1.5 vs 2.2 days;<i>P</i> &lt; .001); and ICU utilization was 254% higher (6.5% vs 23.0%;<i>P</i> &lt; .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%;<i>P</i> &lt; .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%;<i>P</i> = .01). <h3>Conclusions and Relevance</h3> 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.