The impact of hospital volume on CT usage in the management of pediatric empyema.

INTRODUCTION: The American Pediatric Surgical Association (APSA) recommends reserving chest computed tomography (CT) for severe pediatric empyema, though specific criteria remain vague. Adherence to these guidelines across hospitals is unclear. We hypothesized that lower-volume centers more frequently deviate from guidelines, particularly through increased CT utilization, without improved outcomes. METHODS: Using the Pediatric Health Information System (PHIS), we identified patients aged 3-18 with empyema admitted between 2016-2023 who underwent chest tube placement or video-assisted thoracoscopy (VAT) within 3 days of admission. Patients with abscess, gangrene, other complications, or open thoracotomy were excluded. Forty-eight hospitals were stratified into low-, medium-, and high-volume terciles by total empyema case volumes. Multivariable logistic and Poisson regression models adjusted for demographic and clinical factors. RESULTS: Among 1,698 patients, mean 8-year case volumes were 16.5, 30.1, and 75.9 for low-, medium-, and high-volume hospitals, respectively. High-volume hospitals had 52% lower odds of early chest CT use (OR = 0.48; 95% CI: 0.34-0.68; p < 0.001). Hospital size and presence of a pediatric surgery fellowship were not associated with CT utilization. Length of stay, antibiotic duration, ICU admission, 30-day readmission, and mechanical ventilation did not differ by hospital volume. CONCLUSIONS: Higher-volume centers demonstrate greater adherence to APSA guidelines with lower chest CT utilization, without differences in disease severity or clinical outcomes.