Impact of AAP Guidelines on the Management of Children with Brief Resolved Unexplained Events

Background: In May 2016, the AAP published a clinical practice guideline (CPG) more specifically defining Apparent Life-Threatening Events (ALTEs) as Brief Resolved Unexplained Events (BRUEs) and recommending risk-based management strategies. Little is known about the impact of the CPG on hospitalization, testing, cost and revisits.

Methods: Using the Pediatric Health Information Systems database, we analyzed the association of the CPG publication on admission rate, diagnostic testing, treatment, cost, length of stay, revisits in patients with an ICD-10 code for ALTE/BRUE or clinical features of a BRUE from January 1, 2012, to December 31, 2019. We grouped encounters into two-time cohorts based on discharge date: pre-guideline (January 1st, 2012 to January 31st, 2016) and post-guideline (July 1st, 2016 to December 31st, 2019). We used interrupted time-series (ITS) regression analysis to test if the CPG publication was associated with level change and change in slope for each metric.

Results: The study included 27941 patients with ALTE/BRUE from 36 hospitals. There were 43733 patients with clinical features of BRUE. There was an immediate decrease in 12 of 16 diagnostic tests for which the CPG strongly recommends against. Of these, 6 continued to decrease post-guideline, but the decreased slowed for these measures compared to pre-guideline changes. There was a positive change in the use of EKGs (0.36%) for which the CPG recommends. There was a significant reduction (p < .05) in admissions (-24.64 %), utilization of medications (0.16%), cost (1850.9 versus 1341.5 dollars, p <0.001) and length of stay (1.4 versus 1.3 days, p<0.001) without a change in the revisit rates. In the post-guideline period there were an estimated 2,678 admissions avoided out of 12,508 encounters. Figure 1 and 2 show the ITS for different metrics pre- and post- guidelines. Findings were similar for patients with clinical features of BRUE.

Conclusion: Publication of the AAP BRUE CPG was associated with significant reductions in testing, utilization of medications, admission rates, cost, and length of stay without a change in the revisit rates.