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

Abstract

Objective To describe variation across US pediatric hospitals in the utilization of resources not recommended for routine use by the AAP 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 five 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 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 five resources not recommended for routine use by the AAP 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.

Care Variations and Outcomes for Children Hospitalized With Bacterial Tracheostomy-Associated Respiratory Infections

“…Our results are consistent with previous studies showing wide hospital-level care variation in respiratory diseases (e.g., community-acquired pneumonia 14, 21 , bronchiolitis 22, 23 ) and other pediatric diseases (e.g., tonsillectomy 24 , abscess incision and drainage 25 ). The exact reasons for the wide differences in diagnostic testing and other resource use in this population are unclear.…”

Implementing evidence-based medicine in a busy general hospital department: results and critical success factors

“…We realised that, contrary to popular criticism, EBM does not encourage ‘cookbook medicine’, but permits variation in clinical practice based on differences in expertise or patient values 10. With regard to common paediatric problems such as respiratory tract infections11 and gastro-oesophageal reflux,12 however, evidence allows increasingly strong recommendations for decision making. With our EBM implementation project, we wanted to achieve more uniformity in retrieving, appraising and synthesising such evidence.…”

Validity of Bronchiolitis Outcome Measures

“…1,2 There is wide practice variation in its management, with heterogeneous evidence for many therapeutic approaches. [3][4][5][6][7] Systematic reviews have highlighted various shortcomings in randomized controlled trials (RCTs) in this field. [8][9][10] One of the major issues is the heterogeneous choice of outcome measures.…”