title: Variation in care of the febrile young infant <90 days in US pediatric emergency departments.
abstract: OBJECTIVE
  Variation in patient care or outcomes may indicate an opportunity to improve quality of care. We evaluated the variation in testing, treatment, hospitalization rates, and outcomes of febrile young infants in US pediatric emergency departments (EDs).
  
  
  METHODS
  Retrospective cohort study of infants <90 days of age with a diagnosis code of fever who were evaluated in 1 of 37 pediatric EDs between July 1, 2011 and June 30, 2013. We assessed patient- and hospital-level variation in testing, treatment, and disposition for patients in 3 distinct age groups: ≤28, 29 to 56, and 57 to 89 days. We also compared interhospital variation for 3-day revisits and revisits resulting in hospitalization.
  
  
  RESULTS
  We identified 35,070 ED visits that met inclusion criteria. The proportion of patients who underwent comprehensive evaluation, defined as urine, serum, and cerebrospinal fluid testing, decreased with increasing patient age: 72.0% (95% confidence interval [CI], 71.0-73.0) of neonates ≤28 days, 49.0% (95% CI, 48.2-49.8) of infants 29 to 56 days, and 13.1% (95% CI, 12.5-13.6) of infants 57 to 89 days. Significant interhospital variation was demonstrated in testing, treatment, and hospitalization rates overall and across all 3 age groups, with little interhospital variation in outcomes. Hospitalization rate in the overall cohort did not correlate with 3-day revisits (R(2) = 0.10, P = .06) or revisits resulting in hospitalization (R(2) = 0.08, P = .09).
  
  
  CONCLUSIONS
  Substantial patient- and hospital-level variation was observed in the ED management of the febrile young infant, without concomitant differences in outcomes. Strategies to understand and address the modifiable sources of variation are needed.
authors.affiliation: Department of Pediatrics, Section of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut; paul.aronson@yale.edu.
authors.forename: Paul L
authors.initials: PL
authors.lastname: Aronson
authors.affiliation: Children's Hospital Association, Overland Park, Kansas;
authors.forename: Cary
authors.initials: C
authors.lastname: Thurm
authors.affiliation: Division of Emergency Medicine, Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois;
authors.forename: Elizabeth R
authors.initials: ER
authors.lastname: Alpern
authors.affiliation: Divisions of Emergency Medicine.
authors.forename: Evaline A
authors.initials: EA
authors.lastname: Alessandrini
authors.affiliation: Division of Hospital Medicine, Department of Pediatrics, The Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, Tennessee;
authors.forename: Derek J
authors.initials: DJ
authors.lastname: Williams
authors.affiliation: Hospital Medicine, and Infectious Diseases, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio;
authors.forename: Samir S
authors.initials: SS
authors.lastname: Shah
authors.affiliation: Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts;
authors.forename: Lise E
authors.initials: LE
authors.lastname: Nigrovic
authors.affiliation: Division of Infectious Diseases, Department of Pediatrics, Children's Mercy Hospitals & Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri; and.
authors.forename: Russell J
authors.initials: RJ
authors.lastname: McCulloh
authors.affiliation: Hospital Medicine, and.
authors.forename: Amanda
authors.initials: A
authors.lastname: Schondelmeyer
authors.affiliation: Division of Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington.
authors.forename: Joel S
authors.initials: JS
authors.lastname: Tieder
authors.affiliation: Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts;
authors.forename: Mark I
authors.initials: MI
authors.lastname: Neuman
mesh_terms: D015331:Cohort Studies; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D005334:Fever / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy*; D006776:Hospitals, Pediatric / Q000592:standards*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D038801:International Classification of Diseases / Q000592:standards; D008297:Male; D005791:Patient Care / Q000379:methods / Q000592:standards*; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology
keywords: febrile young infant; fever; low-risk criteria; neonatal sepsis; serious bacterial infection; variation