Elsevier

The Journal of Pediatrics

Volume 165, Issue 4, October 2014, Pages 786-792.e1
The Journal of Pediatrics

Original Article
Variation in the Management of Infants Hospitalized for Bronchiolitis Persists after the 2006 American Academy of Pediatrics Bronchiolitis Guidelines

https://doi.org/10.1016/j.jpeds.2014.05.057Get rights and content

Objective

To describe variation across US pediatric hospitals in the utilization of resources not recommended for routine use by the American Academy of Pediatrics guideline for infants hospitalized with bronchiolitis and to examine the association between resource utilization and disposition outcomes.

Study design

We conducted a cross-sectional study of infants ≤12 months hospitalized for bronchiolitis from 2007-2012 at 42 hospitals contributing data to the Pediatric Health Information System. Patients with asthma were excluded. The primary outcome was hospital-level variation in utilization of 5 resources not recommended for routine use: albuterol, racemic epinephrine, corticosteroids, chest radiography, and antibiotics. We also examined the association of resource utilization with length of stay (LOS) and readmission.

Results

In total, 64 994 hospitalizations were analyzed. After adjustment for patient characteristics, albuterol (median, 52.4%; range, 3.5%-81%), racemic epinephrine (20.1%; 0.6%-78.8%), and chest radiography (54.9%; 24.1%-76.7%) had the greatest variation across hospitals. Utilization of albuterol, racemic epinephrine, and antibiotics did not change significantly over time compared with small decreases in corticosteroid (3.3%) and chest radiography (8.6%) use over the study period. Utilization of each resource was significantly associated with increased LOS without concomitant decreased odds of readmission.

Conclusions

Substantial use and variation in 5 resources not recommended for routine use by the American Academy of Pediatrics bronchiolitis guideline persists with increased utilization associated with increased LOS without the benefit of decreased readmission. Future work should focus on developing processes that can be widely disseminated and easily implemented to minimize unwarranted practice variation when evidence and guidelines exist.

Section snippets

Methods

This multicenter cross-sectional study included inpatient visits of children diagnosed with bronchiolitis. Data were from the PHIS, an administrative database of 43 not-for-profit, tertiary care pediatric hospitals in the US affiliated with the Children's Hospital Association, Shawnee Mission, Kansas. This database accounts for ∼20% of annual pediatric hospitalizations in the US. Data quality and reliability are assured through a joint effort between Children's Hospital Association and

Results

In total, 64 994 inpatient hospitalizations for bronchiolitis from October 2007 through March 2012 were eligible for inclusion and analyzed across the 42 PHIS hospitals (Table I; available at www.jpeds.com). The mean age of the cohort was 3.7 months (SD, 3.2 months). There was a male predominance (57.7%), and government payers insured most study subjects (51.4%). Most patients were classified as having illness of minor (56.6%) or moderate (36.6%) severity and most visits occurred in the winter

Discussion

This multicenter study of children hospitalized for bronchiolitis in 42 pediatric hospitals after the publication of the AAP bronchiolitis guidelines demonstrates significant and substantial variation in 5 resources not routinely recommended by the guideline. A key strength of our study is the examination of resource use and the outcomes of LOS and readmission. Utilization of all 5 resources was associated with increased LOS. We found that resource use was not associated with decreased odds for

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    The authors declare no conflicts of interest.

    Current affiliation is Seattle Children's Hospital, Seattle, WA.

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