Variation in Inpatient Resource Utilization and Management of Apparent Life-Threatening Events

Objective

To report national variations in diagnostic approaches to apparent life-threatening events (ALTEs) and resource utilization.

Study design

Using the Pediatric Health Information System, we studied children who were age 3 days to 5 months at admission and were discharged with an International Classification of Diseases, Ninth Revision (ICD-9) code potentially identifiable as ALTE. Multiple analysis of variance was used to determine whether the variances in adjusted charges, length of stay (LOS), and diagnostic studies were hospital-related after controlling for other covariates. Logistic regression was used to study the association of readmission rates with discharge diagnosis and specific diagnostic studies.

Results

The study group comprised 12,067 patients, with a mean LOS of 4.4 days (standard deviation ± 5.6 days) and mean adjusted charges of $15,567 ($28,510) per admission. The mean in-hospital mortality rate was 0.56% (n = 68), and the rate of 30-day readmission was 2.5%. The most common discharge diagnoses were gastroesophageal reflux 36.9% (48.3%) and lower respiratory tract infection 30.8% (46.2%). Mean LOS, total adjusted charges, and use of diagnostic studies varied considerably across hospitals, and hospital-level differences were a significant contributor to the variance of these outcomes after controlling for covariates (P < .001). There was an increased likelihood of readmission for patients discharged with a diagnosis of cardiovascular disorders (odds ratio [OR] = 1.68; 95% confidence interval [CI] = 1.30 to 2.16) and gastroesophageal reflux (OR = 1.32; 95% CI = 1.03 to 1.69) compared with other discharge diagnoses.

Conclusions

There is considerable hospital-based variation in care for patients hospitalized for conditions potentially identifiable as ALTE, particularly in the evaluation and diagnosis of gastroesophageal reflux, which may contribute to adverse clinical and financial outcomes. An evidence-based national standard of care for ALTE is needed, as are multi-institutional initiatives to study different diagnostic and management strategies and their effect on patient outcomes.

Abbreviations: ALTE, Apparent life-threatening event, ANOVA, Analysis of variance, CI, Confidence interval, GER, Gastroesophageal reflux, GI, Gastrointestinal, ICD-9, International Classification of Diseases, Ninth Revision, LOS, Length of stay, LRTI, Lower respiratory tract infection, OR, Odds ratio, PHIS, Pediatric Health Information System