Variation in Chest Radiograph Use for Children With Complicated Pneumonia Requiring Thoracostomy

BACKGROUND Routine chest radiographs (CXRs) are often used to monitor patients with complicated pneumonia requiring chest tubes. We aim to evaluate the following: (1) variation in CXR ordering; and (2) outcomes such as tube-related complications, length of stay (LOS), costs, and 30-day readmissions among hospitals with differing rates of CXR orders. METHODS Using Pediatric Health Information System (PHIS) data, this study examined children aged 6 months to 18 years with complicated pneumonia receiving thoracostomy between July 2019 and June 2023. Unadjusted and adjusted proportions of number of eligible days that a CXR was obtained following thoracostomy for each encounter were calculated. At the hospital level, the median adjusted proportion of daily CXRs ordered per encounter was calculated. Hospitals were grouped into quartiles by hospital median daily CXR proportions, and adjusted outcomes were compared. RESULTS Of 1817 children, 44.1% were female, and the median age was 5 years. Adjusted median (IQR) daily CXR proportion for all encounters was 0.68 (0.55, 0.81). At the hospital level, the median adjusted proportion of daily CXRs ordered ranged from 0.30 to 0.91, with 20% of hospital IQRs falling outside of the IQR for all encounters. There were no differences in postprocedural pneumothorax, repeated thoracostomy, log post-thoracostomy days, log LOS, or 30-day readmissions across quartiles; however, there were higher log costs among high-use compared with low-use hospitals. CONCLUSIONS Variation exists in CXR ordering among hospitals for patients with complicated pneumonia requiring chest tubes. There were no differences in most outcomes, but high-use hospitals incurred higher costs. Future studies should address clinical factors associated with chest tube complications to guide targeted approaches to CXR ordering.