Establishment of achievable benchmarks of care in the neurodiagnostic evaluation of simple febrile seizures

Abstract

Background: Current guidelines recommend against neurodiagnostic testing for the evaluation of simple febrile seizures.Objectives: (1) Assess overall and institutional rates of neurodiagnostic testing and(2) establish achievable benchmarks of care (ABCs) for children evaluated for simple febrile seizures at children's hospitals. Design, Setting, and Participants: Cross-sectional study of children 6 months to 5 years evaluated in the emergency department (ED) 2016-2019 with simple febrile seizures at 38 children's hospitals in Pediatric Health Information System database.We excluded children with epilepsy, complex febrile seizures, complex chronic conditions, and intensive care.Outcome Measures: Proportions of children who received neuroimaging, electroencephalogram (EEG), or lumbar puncture (LP) and rates of hospitalization for study cohort and individual hospitals. Hospital-specific outcomes were adjusted for patient demographics and severity of illness. We utilized hospital-specific values for each measure to calculate ABCs.Results: We identified 51,015 encounters. Among the study cohort 821 (1.6%) children had neuroimaging, 554 (1.1%) EEG, 314 (0.6%) LP, and 2023 (4.0%) were hospitalized. Neurodiagnostic testing rates varied across hospitals: neuroimaging 0.4%-6.7%, EEG 0%-8.2%, LP 0%-12.7% in patients <1-year old and 0%-3.1% in patients ≥1 year. Hospitalization rate ranged from 0%-14.5%. Measured outcomes were higher among hospitalized versus ED-only patients: neuroimaging 15.3% versus 1.0%, EEG% 24.7 versus 0.1% (p < .001). Calculated ABCs were 0.6% for neuroimaging, 0.1% EEG, 0% LP, and 1.0% hospitalization.Conclusions: Rates of neurodiagnostic testing and hospitalization for simple febrile seizures were low but varied across hospitals. Calculated ABCs were 0%-1% for all measures, demonstrating that adherence to current guidelines is attainable.

Changing patterns of routine laboratory testing over time at children's hospitals

“…Finding an achievable "floor" for testing rates may be useful in situations where the ideal rate of utilization is nuanced or unknown and where undertesting remains a risk. Similar to an achievable benchmark of care (ABC), 20 continue to gather data where we can on the equity and access implications of value improvement work. 39 A positive deviance approach has been posited as an effective method to improve the value of healthcare via studying the specific systems that consistently demonstrate the best performance.…”

“…Finding an achievable “floor” for testing rates may be useful in situations where the ideal rate of utilization is nuanced or unknown and where undertesting remains a risk. Similar to an achievable benchmark of care (ABC), 20 this could be a pragmatic measure based on real‐world practice to quantify what measure of improvement is feasible in healthcare around routine testing. Though less concrete than an ABC, this approach may reduce the risk of miscategorizing undertesting as ideal testing like a straightforward ABC calculation might.…”

“…Outcome measures included LOS in hours, cost of hospitalization in US dollars (estimated from charges using hospital and year‐specific cost‐to‐charge ratios and inflated to 2019 dollars using the medical component of the Consumer Price Index), 30‐day all‐cause readmission rate, and 30‐day all‐cause emergency department (ED) revisit rate. These outcomes are common measures in retrospective and quality improvement studies to measure the effect of changes in utilization directly and as balancing measures against potential adverse outcomes from changes in testing rates 8,11,12,16,18–21 . Outcomes were adjusted for patient severity using the Hospitalization Resource Intensity Scores for Kids (H‐RISK) score, a pediatric‐specific relative cost weight used to measure resource intensity of patient admissions based on the APR‐DRG (3M Health‐care) 22 .…”

“…These outcomes are common measures in retrospective and quality improvement studies to measure the effect of changes in utilization directly and as balancing measures against potential adverse outcomes from changes in testing rates. 8,11,12,16,[18][19][20][21] Outcomes were adjusted for patient severity using the Hospitalization Resource Intensity Scores for Kids (H-RISK) score, a pediatric-specific relative cost weight used to measure resource intensity of patient admissions based on the APR-DRG (3M Health-care). 22 To evaluate if changes in case mix over time impacted results, we also determined hospital-specific case mix indices calculated as the mean H-RISK score of hospitalizations for each hospital and study year.…”