ARTICLE Primary Early Thoracoscopy and Reduction in Length of Hospital Stay and Additional Procedures Among Children With Complicated Pneumonia Results of a Multicenter Retrospective Cohort Study Samir S. Shah, MD, MSCE; Cara M. DiCristina, MPH; Louis M. Bell, MD; Tom Ten Have, PhD; Joshua P. Metlay, MD, PhD Objective: To determine the effect of initial procedure with complicated pneumonia underwent early pleural fluid type on the length of hospital stay (LOS) and on the re- drainage. Initial procedures included chest tube placement quirement for additional pleural fluid drainage proce- (n=714),VATS(n=50),andthoracotomy(n=197).Theme- dures in a large multicenter cohort of children with pneu- dian patient age was 4.0 years (interquartile range, 2.0-8.0 monia complicated by pleural effusion. years). The median LOS was 10 days (interquartile range, 7-14 days). Two hundred ninety-eight patients (31.0%) re- Design: Retrospective cohort study. quired at least 1 additional pleural fluid drainage procedure, and 44 patients (4.6%) required more than 2 pleural fluid Setting: Administrative database containing inpatient re- drainage procedures. In linear regression analysis, children source use data from 27 tertiary care children’s hospitals. undergoingprimaryVATShada24%(adjusted ␤coefficient, −0.24; 95% confidence interval, −0.41 to −0.07) shorter LOS Participants: Patients between 12 months and 18 years than patients undergoing primary chest tube placement ; this of age diagnosed as having complicated pneumonia were translated into a 2.8-day reduction in the LOS for those un- eligible for the study if they were discharged from the dergoing early primary VATS. In logistic regression analy- hospital between January 1, 2001, and December 31, 2005, sis, patients undergoing primary VATS had an 84% (adjusted and underwent early (within 2 days of the index hospi- odds ratio, 0.16; 95% confidence interval, 0.06-0.42) reduc- talization) pleural fluid drainage. tion in the requirement for additional pleural fluid drain- age procedures compared with patients undergoing primary Intervention: Pleural fluid drainage, categorized as chest chest tube placement. tube placement, video-assisted thoracoscopic surgery (VATS), or thoracotomy. Conclusion: Our large retrospective multicenter study demonstrates that, compared with primary chest tube Main Outcome Measures: The LOS and the require- placement, primary VATS is associated with shorter LOS ment for additional pleural fluid drainage. and fewer additional procedural interventions. Results: Nine hundred sixty-one of 2862 patients (33.6%) Arch Pediatr Adolesc Med. 2008;162(7):675-681 Author Affiliations: Divisions OMMUNITY-ACQUIRED Early pleural fluid drainage is thought of Infectious Diseases (Drs Shah pneumonia is the most to improve the outcome of children with and Bell and Ms DiCristina) and common serious bacte- complicated pneumonia.14-18 Drainage General Pediatrics (Drs Shah rial infection occurring in strategies include chest tube placement, and Bell), The Childrens children. In the United video-assisted thoracoscopic surgery Hospital of Philadelphia, CStates, more than 600 000 children re- (VATS), and thoracotomy. VATS allows Departments of Biostatistics and quire hospitalization for pneumonia each for pleural debridement, which is not pos- Epidemiology (Drs Shah, 1,2 Ten Have, and Metlay), year ; up to one-third of these children sible by chest tube placement. Further- Pediatrics (Drs Shah and Bell), develop pneumonia-related pleural effu- more, VATS is less invasive than thora- and Medicine (Dr Metlay), and sion,3,4 a process often referred to as “com- cotomy. However, studies to date have not Center for Clinical plicated pneumonia.” Most children with provided sufficient information on the rela- Epidemiology and Biostatistics complicated pneumonia are hospitalized tive efficacy of these interventions; there- (Drs Shah, Ten Have, and for more than 2 weeks,5-7 undergo mul- fore, there is substantial practice varia- Metlay), University of tiple invasive procedures,8-11 require sev- tion. Current studies5,8-13,16,19-23 have been Pennsylvania School of 4,10,12 Medicine, and Veterans Affairs eral radiologic studies, and receive limited by small sample size, selection bias, Medical Center (Dr Metlay), prolonged courses of antibiotics and an- and failure to adjust for confounding vari- Philadelphia. algesic and sedative medications.13 ables. In a meta-analysis of these studies, (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 162 (NO. 7), JULY 2008 WWW.ARCHPEDIATRICS.COM 675 ©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Avansino et al7 found that primary operative therapy re- fection.25 If a child was hospitalized for complicated pneumo- duced the median length of hospital stay (LOS) by 45% nia more than once during the study period, only the first and the frequency of additional procedures by 90%. How- hospitalization was included in the analysis; subsequent read- ever, interpretation of the meta-analysis results is ham- missions were considered treatment failures if they occurred pered because only observational studies with heteroge- within 14 days of the index discharge. neous study designs were available for inclusion and because analytic measures to exclude the possibility of STUDY DEFINITIONS confounding could not be performed. These limitations Study patients were identified in the PHIS database using the make it difficult to determine the optimal types of thera- ICD-9 codes indicating pleural effusion (code 510.0 [empy- peutic interventions that will lead to the best possible out- ema with fistula], 510.9 [empyema without fistula], 511.1 [pleu- come for children with complicated pneumonia. risy with effusion], or 513.0 [abscess of lung, including ne- The present study comprises a large multicenter co- crotic pneumonia]) as the primary diagnosis and at least 1 hort of children with complicated pneumonia undergo- additional code for pneumonia (codes 480-486). The ICD-9 ing early pleural fluid drainage. We sought to deter- codes for pneumonia show greater than 85% concordance with mine the effect of initial procedure type on the LOS and the diagnosis of pneumonia as determined by medical record on the requirement for additional pleural fluid drainage review26 and have been used in other administrative database 27-29 procedures. studies that helped define key processes of care for com- munity-acquired pneumonia in adults. Pleural drainage pro- cedures were identified by the following ICD-9 codes: code 34.04 METHODS (thoracostomy tube [chest tube]), 34.21 (video-assisted tho- racoscopic surgery [VATS]), or 34.02 or 34.09 (thora- DATA SOURCE cotomy). Readmission related to treatment failure was de- fined as hospitalization with a primary discharge diagnosis of Data for this study were obtained from the Pediatric Health In- pneumonia within 14 days of the discharge date from the in- formation System (PHIS), an administrative database that dur- dex hospitalization. ing the study period contained inpatient data from 42 not-for- profit freestanding pediatric hospitals in the United States.24 DEPENDENT VARIABLES These hospitals are affiliated with a business alliance of chil- dren’s hospitals (Child Health Corporation of America, Shaw- The LOS comprised the first dependent variable. The second nee Mission, Kansas). Data quality and reliability are assured dependent variable was the requirement for an additional pleu- through a joint effort between the Child Health Corporation ral fluid drainage procedure during the index hospitalization. of America and participating hospitals. The data warehouse func- tion for the PHIS database is privately managed (Solucient LLC, INDEPENDENT VARIABLES Evanston, Illinois). For external benchmarking, participating hospitals provide discharge data, including patient demograph- The primary independent variable, initial pleural fluid drain- ics, diagnoses, and procedures. Total hospital charges in the age procedure, was classified into the mutually exclusive cat- PHIS database are adjusted for hospital location using the Cen- egories of chest tube placement, VATS, or thoracotomy. Other ters for Medicare and Medicaid price and wage index. Patients covariates considered for inclusion in the models as potential are deidentified before inclusion in the PHIS database, but a confounders were age, sex, race/ethnicity, season, empirical unique identifier permits tracking of individual patients across antimicrobial therapy, receipt of corticosteroid therapy or multiple admissions to the same hospital. Twenty-seven par- chemical fibrinolysis (ie, intrapleural streptokinase or uroki- ticipating hospitals also submit resource use data for each hos- nase), and the presence of asthma as a comorbid condition. pital discharge (eg, pharmaceutical dispensings and imaging Race/ethnicity was included in the final models because there and laboratory studies); patients from these 27 hospitals were seems to be variation among different racial/ethnic groups eligible for inclusion in this study. The protocol for the con- with respect to outcomes for children hospitalized with pneu- duct of this study was reviewed and approved by The Chil- monia.30 drens Hospital of Philadelphia committees for the protection of human subjects. STATISTICAL ANALYSIS PATIENTS Continuous variables were described using mean, median, range, and interquartile range (IQR) values, while categorical vari- Patients between 12 months and 18 years of age diagnosed