Quality and Safety of Pediatric Inpatient Care in Community Hospitals: A Scoping Review

Radiology

Within the domain of radiology, our review identified no interventional studies.

In this scoping review of the quality and safety of pediatric inpatient care in community hospitals, we identified 44 studies applying heterogeneous study designs and evaluating diverse patient populations and quality outcomes. We identified only one RCT in our search; all the remaining studies applied observational designs.

We found only three clinical areas that were explored in multiple studies, with consistent directionality of results: (1) perinatal regionalization, (2) telemedicine, and (3) imaging radiation. The limited evidence identified in our review suggests that delivery of early premature infants at community hospitals, rather than at tertiary hospitals, may increase risk of neonatal morbidity and/or mortality,^13,16,46 that use of telemedicine may improve the effectiveness and efficiency of intensive or specialized care in community settings,^45,47,52,55 and that CT use and radiation doses may be higher in community hospitals compared with other settings.^38,39,41 However, even within these clinical domains, the literature was limited in amount and heterogeneous; additional research is needed to systematically review the effect of individual interventions or particular community hospital quality outcomes compared with other hospital types.

Our search identified only 14 studies evaluating QI interventions within community hospitals over the almost 30-year review period. Although limited in number, 86% of these demonstrated improvements in healthcare quality and safety, providing a positive “proof of concept” that pediatric care in community hospitals can be improved by multidisciplinary efforts and be sustained over time.^{43-47,49,51-56} As pediatric departments within community hospitals may have limited resources, aligning pediatric QI efforts with adult initiatives within the same hospitals could prove advantageous. However, we did not identify any studies meeting our inclusion criteria that took this approach. Alternatively, QI collaboratives across structurally diverse hospitals may provide valuable infrastructure for QI in community hospitals. For example, the Value in Inpatient Pediatrics Network has conducted several multisite QI initiatives that have engaged both children’s and community hospitals.^57-60 However, none of these studies have reported community hospital-specific quality outcomes, resulting in their exclusion from this review. In future study, researchers may consider separating community hospital results from those of pediatric hospitals to highlight the effect of community hospital-specific QI efforts and to allow valuable direct comparisons between hospital types.

Many studies identified in our scoping review were conducted at single hospitals. Sample sizes were often very small and power calculations were rarely reported, raising questions about the validity of the “nonsignificant” differences reported by some. Although such single-center studies provide valuable information for local improvement of inpatient care, by design the findings from these studies are unlikely generalizable to other community hospital systems. Without inclusion of another hospital type and/or quality measures with clear national benchmark for comparison, the additional conclusions that can be drawn from these studies are limited. In comparison, many of the multicenter studies had large study samples, but more than half used data registries with limited data to evaluate outcomes, clinical context, or important covariates.^{13,20,21,25,27-30,34,35,37,39} The most frequently reported outcomes in these data sets—hospital charges and lengths of stay—are of limited utility in understanding healthcare quality without clear benchmarks. As a result, the evidence-base from which to draw conclusions about quality and safety in community hospitals is very limited.

Therefore, our review highlights a great need for additional research in community hospital medicine and the need for high-quality evidence generation. Risk of bias was moderate or high for the majority of included studies because of inadequate risk adjustment or statistical analysis. In the future, multicenter collaborations may help to connect research methodologists with community hospital teams to aid in the application of robust study designs and analytic techniques. Multisite collaboration may also overcome the limitation of small sample sizes that are a reality at many community hospitals.

Our study findings must be considered in the setting of several methodological limitations. The lack of a standard definition for a community hospital has led to inconsistent terms and hospital definitions used in the literature. It is possible that, while following our systematic approach to define a community hospital, we inadvertently missed relevant studies that used different terms. We also excluded unpublished articles. Given that publication bias tends to favor studies with significant associations, it is possible that some studies with insignificant changes in quality outcomes were missed. Finally, in our exclusion of all non-US studies, we may have unknowingly missed literature from countries with community hospital definitions similar to those in the United States.