Corticosteroids for acute chest syndrome in children with sickle cell disease: variation in use and association with length of stay and readmission

Abstract

Acute chest syndrome (ACS) causes significant morbidity and mortality in sickle cell disease. The role of corticosteroids is unclear. The objectives of our study were to examine the variation between hospitals in their use of corticosteroids for ACS, describe characteristics associated with corticosteroids, and investigate the association between corticosteroids, length of stay, and readmission. We performed a retrospective examination of 5,247 hospitalizations for ACS between January 1, 2004, and June 30, 2008, at 32 hospitals in the Pediatric Health Information System database. We used multivariate regression to examine the variability in the use of corticosteroids adjusting for hospital case mix, identify factors associated with corticosteroid use, and evaluate the association of corticosteroids with length of stay and 3-day readmission rates controlling for propensity score. Corticosteroid use varied greatly by hospital (10-86% among all patients, 18-92% in patients with asthma). Treatment with corticosteroids was associated with comorbid asthma (OR 3.9, 95% CI: 3.2-4.8), inhaled steroids (OR 1.4, 95% CI: 1.1-1.7), bronchodilators (OR 3.2, 95% CI: 2.5-4.2), nitric oxide (OR 2.4, 95% CI: 1.2-5.0), oxygen (OR 2.3, 95% CI: 1.8-2.9), ICU (OR 1.7, 95% CI: 1.3-2.3), ventilation (OR 2.0, 95% CI: 1.4-2.8), APR-DRG severity level (OR 1.4, 95% CI: 1.2-1.6), and discharge year (OR 0.86, 95% CI: 0.80-0.92). Corticosteroids were associated with an increased length of stay (25%, 95% CI: 14-38%) and a higher 3-day readmission rate (OR 2.3, 95% CI: 1.6-3.4), adjusted for confounding. Hospitals vary greatly in the use of corticosteroids for ACS, even in patients with asthma. Clear evidence of the efficacy and toxicity of corticosteroid treatment in ACS may reduce variation in care.

Figure 1

Variation in corticosteroid use by hospital using standardized case mix: (A) all patients, (B) patients with asthma, and (C) patients without asthma.

Figure 2

Variation in corticosteroid use by hospital for a standardized patient with severe ACS.