Patterns of Inpatient Care for Acute Immune Thrombocytopenic Purpura in U.S. Children's Hospitals, 2008–2010

A state of equipoise exists in the pediatric hematology community regarding the management of acute immune thrombocytopenic purpura (ITP). While studies have established that ITP treatment raises platelet counts, there is no evidence that treatment prevents serious hemorrhage. Recent guidelines from both an international expert panel and the American Society of Hematology recommend that children with no or mild bleeding be managed with observation alone, and hospitalization be reserved for those with clinically significant bleeding. There are no published data regarding current patterns of inpatient care for pediatric ITP, and the impact of guidelines on clinical practice cannot be determined unless a baseline is established. The objective of this study was to better understand current national practice patterns for acute ITP in United States children's hospitals and investigate regional differences in care.

We examined data from the Pediatric Health Information System, a proprietary database containing clinical and financial data from 43 U.S. children's hospital. Hospitals were divided into regions based on U.S. Census divisions. Data were extracted for all inpatients with ITP (ICD-9 code 287.31) aged 1–18 years discharged in 2008–2010. As our aim was to describe practice patterns for newly diagnosed acute ITP, patients were excluded if they had an ITP-related admission within six months prior to the study period. In patients with multiple ITP admissions during the study period, only the first admission was analyzed. To minimize the number of patients with thrombocytopenia due to other causes (ITP coding errors), we excluded those with other diagnoses associated with thrombocytopenia, such as cancer and lupus. We compared treatment strategies, length of stay, readmissions within 60 days, and total charges by region. Statistical analyses included χ² tests for categorical outcomes and Kruskal-Wallis tests for ordinal outcomes.

Between 2008 and 2010, we identified 2,314 unique patients meeting the study diagnosis of acute ITP (Table). Only 13.1% of patients had an ICD-9 code suggestive of significant bleeding, with epistaxis the most commonly reported symptom. Even in our hospitalized population, <1% of patients had a diagnosis code of intracranial hemorrhage. We identified significant variation (p<0.05) by geographic region in all examined parameters (treatment strategies, length of stay, hospital charges, and likelihood of readmission). In all geographic regions, IVIG was the most utilized treatment strategy. The use of IVIG as a solitary therapy ranged from 66.2% of patients in Pacific states to 85.0% of patients in the West North Central region (MN, MO, KS). Mean length of stay ranged from 1.0–2.0 days among regions, with mean total charges per admission ranging from $12,460 in the New England/Mid-Atlantic region to $21,623 in the West South Central region (AR, LA, TX). Pharmacy costs accounted for 50% of charges. Rates of readmission within 60 days of initial ITP admission ranged from 5.5%-14.4% of patients.

This analysis of the Pediatric Health Information System identified geographic variability in the use of ITP therapies and costs of care for children hospitalized with acute ITP in U.S. children's hospitals. While our data source did not allow us to determine platelet count or indication for hospitalization, our results suggest that a large number of children admitted with ITP in recent years did not have clinically significant bleeding, and potentially could have been managed with outpatient observation. Future studies will be able to identify if the number of ITP admissions, costs of care, and geographic variability in care decrease with the dissemination and implementation of recently published clinical guidelines.

No relevant conflicts of interest to declare.