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Inter-hospital variation in the utilization of diagnostics and their proportionality in the management of adult community-acquired pneumonia

机译：医院间诊断方法的使用差异及其在成人社区获得性肺炎管理中的比例性

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Background Utilization of diagnostics and biomarkers are the second largest cost drivers in the management of patients hospitalized with community-acquired pneumonia (CAP). The present study aimed to systematically assess the inter-hospital variation in these cost drivers in relation to antibiotic use in CAP. Methods Detailed resource utilization data from 300 patients who participated in a multicenter placebo-controlled trial investigating dexamethasone as adjunctive treatment for community-acquired pneumonia was grouped into 3 categories: clinical chemistry testing, radiological exams, and microbiological testing. Based on the identified top 5 items per category, average costs were calculated per category and per hospital. Antibiotic de-escalation at day 3 and secondary ICU admission were assessed as outcomes for proportionality of diagnostics use. Results The mean costs for diagnostics varied between hospitals from 350 (SD 31) to 841 (SD 37) euro per patient ( p ?0.001). This difference was primarily explained by variation in costs for microbiological testing (mean 195 vs. 726 euro per patient, p ?0.001). There was no difference in number of secondary ICU admissions but there was an inverse association between the costs of microbiological testing and level of antibiotic de-escalation. De-escalation occurred most frequently in the hospital with the lowest cost for microbiological testing (48% vs. 30%; p =?0.018). The latter hospital had an automated physician alert system in place to consider a timely iv-to-oral switch of antibiotics. Conclusions Large inter-hospital variation exists in resource utilization, mainly in microbiological diagnostics in the management of adult patients with community-acquired pneumonia. A counterintuitive inverse association between the magnitude of these costs and the amount of antibiotic de-escalation was found. Future studies about the optimal cost-effective set of microbiological testing for antimicrobial stewardship in pneumonia patients should acknowledge the interaction between testing, way of communication of results and triggered physician alert systems. Trial registration ClinicalTrials.gov NCT01743755 .
机译：背景技术在社区获得性肺炎（CAP）住院患者的管理中，诊断和生物标志物的使用是第二大成本驱动因素。本研究旨在系统地评估这些成本驱动因素与CAP中抗生素使用相关的医院间差异。方法将来自300名参加地塞米松辅助治疗社区获得性肺炎的多中心安慰剂对照试验的300名患者的资源利用数据分为三类：临床化学测试，放射学检查和微生物学测试。根据确定的每个类别的前5个项目，计算每个类别和每个医院的平均成本。将第3天的抗生素降级和二次ICU入院评估为诊断使用比例的结果。结果医院之间诊断的平均成本在每位患者350欧元（标准差31）到841欧元（标准差37）之间（p <0.001）。这种差异主要是由于微生物检测费用的差异（每位患者平均195欧元对726欧元，p <0.001）所致。二次加护病房的入院人数没有差异，但微生物检测费用和抗生素降级水平之间存在负相关关系。降级在医院中最常见，且进行微生物检测的费用最低（48％比30％; p =？0.018）。后者的医院配备了自动医生警报系统，以考虑及时进行抗生素从静脉到口服的转换。结论成年社区获得性肺炎患者的资源利用存在较大的院际差异，主要是在微生物学诊断中。发现这些成本的幅度与抗生素降级的数量之间存在反常的逆相关性。关于针对肺炎患者进行抗菌药物管理的最佳微生物检测方法的最佳性价比组合的未来研究应认识到检测方法，结果的传达方式和触发的医生警报系统之间的相互作用。试用注册ClinicalTrials.gov NCT01743755。

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