Hospitals Vary Widely in Management of Infant Bronchiolitis

Nicola M. Parry, DVM

November 28, 2017

Among infants hospitalized with bronchiolitis, use of evidence-based supportive therapies (EBST) varies widely across hospitals, a new study shows.

Suzanne Schuh, MD, FRCP(C), from the University of Toronto, Ontario, Canada, and colleagues published the results of their international study online November 28 in Pediatrics.

"[W]e found that more than 30% of infants hospitalized for bronchiolitis did not receive any EBSTs," the authors write.

"Hospitalization with the receipt of EBSTs, use of nonrecommended pharmacotherapies and chest radiography varied by site."

Bronchiolitis is the most common cause of hospitalization for infants in the United States and contributes to millions of dollars in healthcare costs.

According to the authors, national guidelines recommend limiting use of treatments and diagnostic testing for infants with bronchiolitis. However, because the evidence predominantly targets the inpatient population, an important knowledge gap persists regarding resource use for management of infant bronchiolitis in emergency departments (EDs).

"Given the high-financial burden of hospitalizations and risks of unnecessary hospitalizations of patients with bronchiolitis, it is important to examine therapeutic interventions administered in infants presenting with bronchiolitis to the ED during their ED or inpatient management," the authors note.

Therefore, they aimed to investigate variation between hospital sites and networks in receipt of EBSTs among infants hospitalized with bronchiolitis, as well as variation in use of nonrecommended pharmacotherapies and chest radiography.

The researchers conducted a retrospective cohort study, performing chart reviews of 3725 previously healthy infants younger than 12 months who were diagnosed with bronchiolitis across 38 pediatric EDs in 8 countries. All hospitals belonged to one of six pediatric emergency research networks.

The study excluded infants with a previous diagnosis of bronchiolitis 1 or more months before the index episode, as well as those with various other conditions such as coexistent lung disease or congenital heart disease.

The study found that 1466 (39.4%) of the 3725 infants were hospitalized. However, only 1023 (69.8%) of the hospitalized infants received EBST.

Use of EBST varied across hospital sites (P < .001), the authors say, ranging from 20% in the United Kingdom and Ireland to 37% in the United States. In addition, rates per site ranged from 6.1% to 99.0% (median, 23.4%; 95% confidence interval [CI], 17.9% - 28.3%; interquartile range, 15% - 33%).

The researchers identified several significant multivariable predictors of receiving EBST, including age (odds ratio [OR], 0.90), oxygen saturation (OR, 1.32), apnea (OR, 3.40), dehydration (OR, 3.22), nasal flaring and/or grunting (OR, 2.40), poor feeding (OR, 2.11), chest retractions (OR, 1.90), and respiratory rate (OR, 1.16).

Use of EBST did not vary by network (P = .20).

However, use of pharmacotherapy and chest radiography varied across hospital sites and networks (P < .001 for both), the authors note. Use of at least one pharmacotherapy ranged from 2% to 79% across hospital sites, and from 9% to 58% across networks, and the rate of radiography ranged from 1.6% to 80.8% across hospital sites, and from 10% to 35% across networks.

The authors suggest that the relatively high rate of EBST use and its marked intersite variation in this study may in part be a result of differences in local culture, social structure, and access to follow-up.

They also emphasize that although most hospitals had guidelines for EBST use, uptake and use of these recommendations may also vary.

"The future creation of an international practice guideline may help unify the standards of care for children with bronchiolitis," Dr Schuh and colleagues conclude.

The authors have reported no financial conflicts of interest.

Pediatrics. Published online November 28, 2017. Abstract

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