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Eric Coon, MD, MSCI
Assistant Professor of Pediatrics
University of Utah
Overdiagnosis of Coronary
Artery Abnormalities among
Children with Kawasaki
Disease
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Eric Coon has documented no financial
relationships to disclose or Conflicts of
Interest (COIs) to resolve.
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Acknowledgements
• Susan Bratton, MD, MPH
• Critical Care, University of Utah
• Jacob Wilkes
• Data Analyst, Intermoutain
• Raj Srivastava, MD, MPH
• Associate VP of Research, Intermountain
• Nelangi Pinto, MD
• Cardiology, University of Utah
• Ron Reeder, PhD
• Critical Care, University of Utah
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Background
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Background
Newburger et al. Circulation. 2004 Oct.
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Background
RCT: IVIG/Aspirin vs Aspirin alone
7/24 CAA resolved within 5 weeks
Newburger et al. N Engl J Med. 1986 Aug.
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Methods
Weiner et al. BMJ. 2014 Jul.
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Methods
• Retrospective cohort
• Children hospitalized for Kawasaki Disease
• Between Jan 2000-Dec 2014
• Mixed effects regression adjusting for:
• insurance type
• clustering within hospitals
• age
• gender
• race
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PHIS Network
9
Seattle
Oakland
Palo Alto
Madera
Los Angeles
Orange
San Diego
Phoenix
Salt Lake City
Denver
Austin
Dallas
Fort Worth
Corpus Christi
Houston
Little Rock
New Orleans
Birmingham
Memphis
Nashville
Atlanta
St. Petersburg
Miami
Boston
Hartford
New York
Philadelphia
DC
Norfolk
Pittsburgh
Dayton
Columbus
Cincinnati
Akron
Buffalo
Milwaukee
Chicago
St. Louis
Detroit
Indianapolis
Minnesota
Omaha
Kansas City
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PHIS Network
• 46 tertiary-care children’s hospitals
• ~20% of all annual U.S. pediatric hospitalizations
• De-identified administrative data: demographic, diagnostic, procedure, daily charge data (pharmacy, lab, imaging, supply, clinical)
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Bad Outcome Definition
• Mortality
• Diagnosis codes: cardiac arrest, heart failure, ischemic heart disease
• Procedure codes: angioplasty, CABG, heart transplant, CPR
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Severe CAA Definition
• 1. Presence of a CAA AND
• 2. Receipt of low-molecular weight heparin, coumadin, or anti-platelet agent
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Cohort
Demographic Characteristics of Patients, N=17,919
Male, n (%) 10,859 (60) Age at first admission <1 y, n (%) 3,084 (17) 1-4 y, n (%) 10,620 (59) 5-9 y, n (%) 3,596 (20) 10-18 y, n (%) 619 (4) Race/ethnicity White, non-hispanic, n (%) 7,024 (39) Hispanic, n (%) 3,655 (20) Black, n (%) 2,222 (12) Asian, n (%) 986 (6) Other, n (%) 1,720 (10) Unknown, n (%) 2,312 (13)
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CAA and Bad Outcome Rates
Year
Rate
per
1,0
00 K
D P
atients
4.5 (3.4 to 5.5) CAA
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CAA and Bad Outcome Rates
Year
Rate
per
1,0
00 K
D P
atients
4.5 (3.4 to 5.5)
-0.3 (-0.9 to 0.2)
CAA
Bad Outcome
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Coronary Artery Abnormalities
Percentage of each morbidity among patients who
experienced a bad outcome, N=365
Outcome %
Ischemic Heart Disease 44 Heart Failure 32 Conduction Disorders 15 Cardiomyopathy 12 Cardiogenic Shock 12 Operation Vessels 6 Mortality 5 Conversion 4 Cardiac Arrest 4 Heart Replacement 2
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Types of CAA
Year
Rate
per
1,0
00 K
D P
atients
4.1 (3.2 to 5.1)
0.3 (-0.1 to 0.8)
Non-severe CAA
Severe CAA
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Other Trends
Proportion of Cohort (%)
Change per 1,000 KD patients per year (95% CI)
Imaging Patients who receive an echo 94 3.1 (2.3 to 4.0) Procedures Cardiac Catheterization 1.3 -0.8 (-1.2 to -0.4) Medications Multiple IVIG doses 22 1.5 (0.0 to 3.1) Steroids 18 1.6 (0.1 to 3.0) Immune Modulator 7.7 4.6 (4.0 to 5.1) Any anticoagulation 2.9 0.0 (-0.6 to 0.6)
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Limitations
• Observational design, relying on administrative data
• No radiographic reports
• Outcome ascertainment bias
• Possibility that improved treatment matches increased disease
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Significance
• Unnecessary treatment (and side effects)
• Additional testing and follow up
• Cost
• Vulnerable child syndrome
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Implications
• Echo testing schedule
• CAA diagnostic criteria
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Questions and Comments