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Diagnostic Testing During Pediatric Hospitalizations: The Role of Attending In-House Coverage and Daytime Exposure

  • Kira L. Ryskina
    Correspondence
    Address correspondence to Kira L. Ryskina, MD, MS, MSHP, Division of General Internal Medicine, University of Pennsylvania, 12-30 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104
    Affiliations
    Division of General Internal Medicine, University of Pennsylvania (KL Ryskina), Philadelphia, Pa

    Leonard Davis Institute of Health Economics, University of Pennsylvania (KL Ryskina, R Stein, and E Fieldston), Philadelphia, Pa
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  • Linda Dynan
    Affiliations
    Department of Economics and Finance, Northern Kentucky University (L Dynan), Highland Heights, Ky

    Anderson Center for Health System Excellence, Cincinnati Children's Hospital Medical Center (L Dynan), Cincinnati, Ohio
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  • Rebecca Stein
    Affiliations
    Leonard Davis Institute of Health Economics, University of Pennsylvania (KL Ryskina, R Stein, and E Fieldston), Philadelphia, Pa
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  • Evan Fieldston
    Affiliations
    Leonard Davis Institute of Health Economics, University of Pennsylvania (KL Ryskina, R Stein, and E Fieldston), Philadelphia, Pa

    Division of General Pediatrics, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia (E Fieldston), Philadelphia, Pa
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  • Deepak Palakshappa
    Affiliations
    Division of General Internal Medicine, Wake Forest School of Medicine (D Palakshappa), Winston-Salem, NC
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Published:October 21, 2019DOI:https://doi.org/10.1016/j.acap.2019.09.008

      Abstract

      Objective

      Overuse of diagnostic tests is of particular concern for pediatric academic medical centers. Our objective was to measure variation in testing based on proportion of hospitalization during the day versus night and the association between attending in-house coverage on the teaching service and test utilization for hospitalized pediatric patients.

      Methods

      Electronic health record data from 11,567 hospitalizations to a large, Northeastern, academic pediatric hospital were collected between January 2007 and December 2010. The patient-level dataset included orders for laboratory and imaging tests, information about who placed the order, and the timing of the order. Using a cross-sectional effect modification analysis, we estimated the difference in test utilization attributable to attending in-house coverage.

      Results

      We found that admission to the teaching service was independently associated with higher utilization of laboratory and imaging tests. However, the number of orders was 0.76 lower (95% confidence interval:−1.31 to −0.21, P = .006) per 10% increase in the proportion in the share of the hospitalization that occurred during daytime hours on the teaching services, which is attributable to direct attending supervision.

      Conclusions

      Direct attending care of hospitalized pediatric patients at night was associated with slightly lower diagnostic test utilization.

      Keywords

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      References

        • Eden J
        • Berwick DM
        • Wilensky GR
        Institute of Medicine (U.S.). Committee on the Governance and Financing of Graduate Medical Education.
        Graduate Medical Education That Meets the Nation's Health Needs. The National Academies Press, Washington, D.C2014
        • Chen C
        • Petterson S
        • Phillips R
        • et al.
        Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries.
        JAMA. 2014; 312: 2385-2393
        • Ryskina KL
        • Dine CJ
        • Kim EJ
        • et al.
        Effect of attending practice style on generic medication prescribing by residents in the clinic setting: an observational study.
        J Gen Intern Med. 2015; 30: 1286-1293
      1. House Ways and Means Committee Rept N-, March 4, 1983 and Senate Finance Committee Rept, No. 98-23, March 11, 1983. Accessed on July 30, 2019 at https://www.congress.gov/bill/98th-congress/house-bill/1900.

        • Imrie KR
        • Frank JR
        • Parshuram CS
        Resident duty hours: past, present, and future.
        BMC Med Educ. 2014; 14: S1
        • Patel MS
        • Volpp KG
        • Small DS
        • et al.
        Association of the 2011 ACGME resident duty hour reforms with mortality and readmissions among hospitalized Medicare patients.
        JAMA. 2014; 312: 2364-2373
        • Volpp KG
        • Rosen AK
        • Rosenbaum PR
        • et al.
        Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform.
        JAMA. 2007; 298: 984-992
        • Volpp KG
        • Rosen AK
        • Rosenbaum PR
        • et al.
        Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform.
        JAMA. 2007; 298: 975-983
        • Volpp KG
        • Small DS
        • Romano PS
        • et al.
        Teaching hospital five-year mortality trends in the wake of duty hour reforms.
        J Gen Intern Med. 2013; 28: 1048-1055
        • Press MJ
        • Silber JH
        • Rosen AK
        • et al.
        The impact of resident duty hour reform on hospital readmission rates among Medicare beneficiaries.
        J Gen Intern Med. 2011; 26: 405-411
        • Wachter RM
        • Goldman L
        Zero to 50,000—the 20th anniversary of the hospitalist.
        N Engl J Med. 2016; 375: 1009-1011
        • Farnan JM
        • Burger A
        • Boonyasai RT
        • et al.
        Survey of overnight academic hospitalist supervision of trainees.
        J Hosp Med. 2012; 7: 521-523
        • Palakshappa D
        • Carter LP
        • El Saleeby CM
        Discrepancies in after-hours communication attitudes between pediatric residents and supervising physicians.
        J Pediatr. 2015; 167 (1429-1435. e1422)
        • Farnan JM
        • Petty LA
        • Georgitis E
        • et al.
        A systematic review: the effect of clinical supervision on patient and residency education outcomes.
        Acad Med. 2012; 87: 428-442
        • Vukkadala N
        • Auerbach A
        • Maselli JH
        • et al.
        Association between ordering patterns and shift-based care in general pediatrics inpatients.
        J Hosp Med. 2016; 11: 210-214
        • Feudtner C
        • Feinstein JA
        • Zhong W
        • et al.
        Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation.
        BMC Pediatr. 2014; 14: 199
        • Feudtner C
        • Hays RM
        • Haynes G
        • et al.
        Deaths attributed to pediatric complex chronic conditions: national trends and implications for supportive care services.
        Pediatrics. 2001; 107: E99
        • Blackwell M
        • Iacus S.
        • King G.
        • et al.
        CEM: Coarsened exact matching in STATA.
        Stata J. 2009; 9: 524-546
        • King G
        • Nielsen R
        Why propensity scores should not be used for matching.
        Political Anal. 2019; 27: 1-20
        • Williams R
        Using the margins command to estimate and interpret adjusted predictions and marginal effects.
        Stata J. 2012; 12: 308-331
        • Doyle Jr., JJ
        • Ewer SM
        • Wagner TH
        Returns to physician human capital: evidence from patients randomized to physician teams.
        J Health Econ. 2010; 29: 866-882
        • Kaiser SV
        • Bakel LA
        • Okumura MJ
        • et al.
        Risk factors for prolonged length of stay or complications during pediatric respiratory hospitalizations.
        Hosp Pediatr. 2015; 5: 461-473
        • Lammers RL
        • Roiger M
        • Rice L
        • et al.
        The effect of a new emergency medicine residency program on patient length of stay in a community hospital emergency department.
        Acad Emerg Med. 2003; 10: 725-730
        • Kerlin MP
        • Small DS
        • Cooney E
        • et al.
        A randomized trial of nighttime physician staffing in an intensive care unit.
        N Engl J Med. 2013; 368: 2201-2209
        • Morales IJ
        • Peters SG
        • Afessa B
        Hospital mortality rate and length of stay in patients admitted at night to the intensive care unit.
        Crit Care Med. 2003; 31: 858-863
        • Nasca TJ
        • Day SH
        • Amis Jr., ES
        • et al.
        The new recommendations on duty hours from the ACGME Task Force.
        N Engl J Med. 2010; 363: e3
        • Holmboe ES
        • Call S
        • Ficalora RD
        Milestones and competency-based medical education in internal medicine.
        JAMA Intern Med. 2016; 176: 1601-1602
        • Ryskina KL
        • Korenstein D
        • Weissman A
        • et al.
        Development of a high-value care subscore on the internal medicine in-training examination.
        Ann Intern Med. 2014; 161: 733-739
        • Ryskina KL
        • Smith CD
        • Weissman A
        • et al.
        U.S. internal medicine residents' knowledge and practice of high-value care: a national survey.
        Acad Med. 2015; 90: 1373-1379