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Hunter S, Crawford H, Ao BT, Grant C. Methods to Reduce Cost of Treatment in Childhood Bone and Joint Infection: A Systematic Review. JBJS Rev 2024; 12:01874474-202405000-00007. [PMID: 38814570 DOI: 10.2106/jbjs.rvw.24.00043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
BACKGROUND Childhood bone and joint infection (BJI) is a potentially severe disease with consequences for growth and development. Critically unwell children may require prolonged hospitalization and multiple surgeries. Acknowledging rising healthcare costs and the financial impact of illness on caregivers, increased efforts are required to optimize treatment. This systematic review aims to characterize existing costs of hospital care and summarize strategies, which reduce treatment expense. METHODS A systematic review of the literature was performed from January 1, 1980, to January 31, 2024. Data were extracted on hospitalization costs for pediatric BJI by decade and global region. Results have been converted to cost per day in US dollars with purchase parity for 2023. Studies reporting innovations in clinical care to reduce length of stay (LOS) and simplify treatment were identified. Studies trialing shorter antibiotic treatment were only included if they specifically reported changes in LOS. RESULTS Twenty-three studies met inclusion criteria; of these, a daily hospitalization cost could be derived from 7 publications. Overall hospitalization cost and inpatient charges rose steeply from the 1990s to the 2020s. By contrast, average LOS seems to have decreased. Cost per day was higher in the United States than in Europe and higher for cases with confirmed methicillin-resistant Staphylococcus aureus. Sixteen studies report innovations to optimize care. For studies where reduced LOS was achieved, early magnetic resonance imaging with immediate transfer to theater when necessary and discharge on oral antibiotics were consistent features. CONCLUSION Rising costs of hospital care and economic consequences for families can be mitigated by simplifying treatment for childhood BJI. Hospitals that adopt protocols for early advanced imaging and oral antibiotic switch may provide satisfactory clinical outcomes at lower cost. LEVEL OF EVIDENCE Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sarah Hunter
- University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
- Orthopaedic Department, Starship Hospital, Auckland, New Zealand
| | - Haemish Crawford
- University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
- Orthopaedic Department, Starship Hospital, Auckland, New Zealand
| | - Braden Te Ao
- University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
- School of Population Health and Health Economics, University of Auckland, Auckland, New Zealand
| | - Cameron Grant
- University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
- Department of Child and Youth Health, Starship Hospital, Auckland, New Zealand
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2
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Searns JB, Rice JD, Bertin KB, Birkholz M, Barganier LB, Creech CB, Downes KJ, Hubbell BB, Kronman MP, Rolsma SL, Sydney GI, O'Leary ST, Parker SK, Dominguez SR. Using Administrative Billing Codes to Identify Acute Musculoskeletal Infections in Children. Hosp Pediatr 2023; 13:182-195. [PMID: 36601701 DOI: 10.1542/hpeds.2022-006821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Acute hematogenous musculoskeletal infections (MSKI) are medical emergencies with the potential for life-altering complications in afflicted children. Leveraging administrative data to study pediatric MSKI is difficult as many infections are chronic, nonhematogenous, or occur in children with significant comorbidities. The objective of this study was to validate a case-finding algorithm to accurately identify children hospitalized with acute hematogenous MSKI using administrative billing codes. METHODS This was a multicenter validation study using the Pediatric Health Information System (PHIS) database. Hospital admissions for MSKI were identified from 6 PHIS hospitals using discharge diagnosis codes. A random subset of admissions underwent manual chart review at each site using predefined criteria to categorize each admission as either "acute hematogenous MSKI" (AH-MSKI) or "not acute hematogenous MSKI." Ten unique coding algorithms were developed using billing data. The sensitivity and specificity of each algorithm to identify AH-MSKI were calculated using chart review categorizations as the reference standard. RESULTS Of the 492 admissions randomly selected for manual review, 244 (49.6%) were classified as AH-MSKI and 248 (50.4%) as not acute hematogenous MSKI. Individual algorithm performance varied widely (sensitivity 31% to 91%; specificity 52% to 98%). Four algorithms demonstrated potential for future use with receiver operating characteristic area under the curve greater than 80%. CONCLUSIONS Identifying children with acute hematogenous MSKI based on discharge diagnosis alone is challenging as half have chronic or nonhematogenous infections. We validated several case-finding algorithms using administrative billing codes and detail them here for future use in pediatric MSKI outcomes.
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Affiliation(s)
- Justin B Searns
- Department of Pediatrics, Section of Hospital Medicine.,Department of Pediatrics, Section of Infectious Disease
| | - John D Rice
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, Colorado.,Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado
| | - Kaitlyn B Bertin
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, Colorado
| | | | - Lori B Barganier
- Department of Pediatrics, Section of Infectious Disease, Washington University School of Medicine, St. Louis, Missouri
| | - C Buddy Creech
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kevin J Downes
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brittany B Hubbell
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio.,Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Matthew P Kronman
- Department of Pediatrics, Section of Infectious Diseases, University of Washington, Seattle, Washington
| | - Stephanie L Rolsma
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Guy I Sydney
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sean T O'Leary
- Department of Pediatrics, Section of Infectious Disease.,Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, Colorado
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Schroeder AR, Desai S, Hess LM. Intravenous Antibiotic Durations: "Short" Wins Again. Hosp Pediatr 2022; 12:e269-e272. [PMID: 35726557 DOI: 10.1542/hpeds.2022-006719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Alan R Schroeder
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Sanyukta Desai
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Lauren M Hess
- Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
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Searns JB. Delaying antimicrobials for pediatric bone and joint infections: Balancing clinical risks with diagnostic benefits. Front Pediatr 2022; 10:975221. [PMID: 36389360 PMCID: PMC9659623 DOI: 10.3389/fped.2022.975221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 10/03/2022] [Indexed: 12/04/2022] Open
Affiliation(s)
- Justin B Searns
- Department of Pediatrics, Sections of Hospital Medicine & Infectious Diseases, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, United States
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Van Belkum A, Gros MF, Ferry T, Lustig S, Laurent F, Durand G, Jay C, Rochas O, Ginocchio CC. Novel strategies to diagnose prosthetic or native bone and joint infections. Expert Rev Anti Infect Ther 2021; 20:391-405. [PMID: 34384319 DOI: 10.1080/14787210.2021.1967745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Bone and Joint Infections (BJI) are medically important, costly and occur in native and prosthetic joints. Arthroplasties will increase significantly in absolute numbers over time as well as the incidence of Prosthetic Joint Infections (PJI). Diagnosis of BJI and PJI is sub-optimal. The available diagnostic tests have variable effectiveness, are often below standard in sensitivity and/or specificity, and carry significant contamination risks during the collection of clinical samples. Improvement of diagnostics is urgently needed. AREAS COVERED We provide a narrative review on current and future diagnostic microbiology technologies. Pathogen identification, antibiotic resistance detection, and assessment of the epidemiology of infections via bacterial typing are considered useful for improved patient management. We confirm the continuing importance of culture methods and successful introduction of molecular, mass spectrometry-mediated and next-generation genome sequencing technologies. The diagnostic algorithms for BJI must be better defined, especially in the context of diversity of both disease phenotypes and clinical specimens rendered available. EXPERT OPINION Whether interventions in BJI or PJI are surgical or chemo-therapeutic (antibiotics and bacteriophages included), prior sensitive and specific pathogen detection remains a therapy-substantiating necessity. Innovative tests for earlier and more sensitive and specific detection of bacterial pathogens in BJI are urgently needed.
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Affiliation(s)
- Alex Van Belkum
- bioMérieux, Open Innovation and Partnerships, 3 Route De Port Michaud, La Balme Les Grottes, France
| | | | - Tristan Ferry
- Service Des Maladies Infectieuses Et Tropicales, Hospices Civils De Lyon, Hôpital De La Croix-Rousse, Lyon, France.,Maladies Infectieuses, Université Claude Bernard Lyon 1, Villeurbanne, France.,Centre Interrégional De Référence Pour La Prise En Charge Des Infections Ostéo-articulaires Complexes (Crioac Lyon), Hôpital De La Croix-Rousse, Lyon, France.,Ciri - Centre International De Recherche En Infectiologie, Inserm, U1111, Université́ Claude Bernard Lyon 1CNRS, UMR5308, Ecole Normale Supérieure De Lyon, Univ Lyon, Lyon, France
| | - Sebastien Lustig
- Maladies Infectieuses, Université Claude Bernard Lyon 1, Villeurbanne, France.,Service De Chirurgie Orthopédique, Hôpital De La Croix-Rousse, Lyon, France
| | - Frédéric Laurent
- Service Des Maladies Infectieuses Et Tropicales, Hospices Civils De Lyon, Hôpital De La Croix-Rousse, Lyon, France.,Ciri - Centre International De Recherche En Infectiologie, Inserm, U1111, Université́ Claude Bernard Lyon 1CNRS, UMR5308, Ecole Normale Supérieure De Lyon, Univ Lyon, Lyon, France
| | | | - Corinne Jay
- bioMérieux, BioFire Development Emea, Grenoble, France
| | - Olivier Rochas
- Corporate Business Development, bioMérieux, Marcy-l'Étoile, France
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Truelove JJ, House SA. Reducing PICC Placement in Pediatric Osteomyelitis: A Diamond in the Deimplementation Rough? Hosp Pediatr 2021; 11:e111-e114. [PMID: 34187790 DOI: 10.1542/hpeds.2021-006029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Jessica J Truelove
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire .,Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Samantha A House
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
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7
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Hester GZ, Nickel AJ, Watson D, Swanson G, Laine JC, Bergmann KR. Improving Care and Outcomes for Pediatric Musculoskeletal Infections. Pediatrics 2021; 147:peds.2020-0118. [PMID: 33414235 DOI: 10.1542/peds.2020-0118] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pediatric musculoskeletal infection (MSKI) is a common cause of hospitalization with associated morbidity. To improve the care of pediatric MSKI, our objectives were to achieve 3 specific aims within 24 months of our quality improvement (QI) interventions: (1) 50% reduction in peripherally inserted central catheter (PICC) use, (2) 25% reduction in sedations per patient, and (3) 50% reduction in empirical vancomycin administration. METHODS We implemented 4 prospective QI interventions at our tertiary children's hospital: (1) provider education, (2) centralization of admission location, (3) coordination of radiology-orthopedic communication, and (4) implementation of an MSKI infection algorithm and order set. We included patients 6 months to 18 years of age with acute osteomyelitis, septic arthritis, or pyomyositis and excluded patients with complex chronic conditions or ICU admission. We used statistical process control charts to analyze outcomes over 2 general periods: baseline (January 2015-October 17, 2016) and implementation (October 18, 2016-April 2019). RESULTS In total, 224 patients were included. The mean age was 6.1 years, and there were no substantive demographic or clinical differences between baseline and implementation groups. There was an 81% relative reduction in PICC use (centerline shift 54%-11%; 95% confidence interval 70-92) and 33% relative reduction in sedations per patient (centerline shift 1.8-1.2; 95% confidence interval 21-46). Empirical vancomycin use did not change (centerline 20%). CONCLUSIONS Our multidisciplinary MSKI QI interventions were associated with a significant decrease in the use of PICCs and sedations per patient but not empirical vancomycin administration.
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Affiliation(s)
| | - Amanda J Nickel
- Research Institute, Children's Minnesota, Minneapolis, Minnesota; and
| | - David Watson
- Research Institute, Children's Minnesota, Minneapolis, Minnesota; and
| | | | - Jennifer C Laine
- Orthopedic Surgery, and.,Gillette Children's Specialty Healthcare, St Paul, Minnesota
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DeVine MN, MacBrayne CE, Williams MC, Pearce K, Wickstrom K, Donaldson N, Parker SK, Searns JB. Long-Term Impact of a Clinical Care Guideline for Pediatric Acute Musculoskeletal Infections: Are Improved Outcomes Sustainable? Hosp Pediatr 2020; 10:1107-1113. [PMID: 33154082 DOI: 10.1542/hpeds.2020-0118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Acute hematogenous musculoskeletal infections are a common cause of hospitalization in children. A locally developed clinical care guideline (CCG) for acute musculoskeletal infections was implemented at our quaternary care pediatric hospital in July 2012. The purpose of this study was to evaluate the long-term sustainability of previously described improvements after CCG implementation. METHODS Clinical outcomes for children hospitalized with musculoskeletal infections at Children's Hospital Colorado from June 2009 through September 2018 were retrospectively reviewed. Patients were included if they had an International Classification of Diseases, Ninth Revision or International Classification of Diseases, 10th Revision discharge diagnosis of acute osteomyelitis, septic arthritis, or pyomyositis and were between 6 months and 18 years of age at admission. Patients with underlying medical complexity or nonhematogenous musculoskeletal infections were excluded. Patients were categorized by date of admission as either "pre-CCG" (June 2009 to June 2011) or "sustain-CCG" (July 2014 to September 2018). Primary outcomes were hospital length of stay and intravenous antimicrobial length of therapy. RESULTS From pre-CCG to sustain-CCG, median length of stay decreased by 1.29 days (5.56 vs 4.27; P < .004) and median length of therapy decreased by 5.04 days (8.33 vs 3.29; P < .0001). Statistical process control charts support that these were sustained improvements many years after CCG implementation. Additional secondary clinical improvements were observed in the sustain-CCG group including faster fever resolution, more consistent blood and source culture acquisition, and decreased central line placement. There was no increase in related readmissions or therapeutic failures in the sustain-CCG group. CONCLUSIONS Implementation of a CCG to standardize care for musculoskeletal infections can be sustained many years after implementation.
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Affiliation(s)
| | | | | | | | | | - Nathan Donaldson
- Orthopedic Surgery, Children's Hospital Colorado, Aurora, Colorado
| | | | - Justin B Searns
- Hospital Medicine and Infectious Diseases, Department of Pediatrics and
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9
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Fehring TK, Fehring KA, Hewlett A, Higuera CA, Otero JE, Tande AJ. What's New in Musculoskeletal Infection. J Bone Joint Surg Am 2020; 102:1222-1229. [PMID: 32675671 PMCID: PMC7431136 DOI: 10.2106/jbjs.20.00363] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | | | | | | | - Jesse E. Otero
- OrthoCarolina Hip & Knee Center, Charlotte, North Carolina
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