Practice Variation in Acute Bronchiolitis: A Pediatric Emergency Research Networks Study

• Published in: Pediatrics (Evanston)
• Main Authors: Schuh, Suzanne, Babl, Franz E, Dalziel, Stuart R, Freedman, Stephen B, Macias, Charles G, Stephens, Derek, Steele, Dale W, Fernandes, Ricardo M, Zemek, Roger, Plint, Amy C, Florin, Todd A, Lyttle, Mark D, Johnson, David W, Gouin, Serge, Schnadower, David, Klassen, Terry P, Bajaj, Lalit, Benito, Javier, Kharbanda, Anupam, Kuppermann, Nathan
• Format: Journal Article
• Language: English
• Published: United States 01.12.2017
• DOI: 10.1542/peds.2017-0842

Studies characterizing hospitalizations in bronchiolitis did not identify patients receiving evidence-based supportive therapies (EBSTs). We aimed to evaluate intersite and internetwork variation in receipt of ≥1 EBSTs during the hospital management of infants diagnosed with bronchiolitis in 38 emergency departments of pediatric emergency research networks in Canada, the United States, Australia, New Zealand, the United Kingdom, Ireland, Spain, and Portugal. We hypothesized that there would be significant variation, adjusted for patient characteristics. Retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was that hospitalization occurred with EBST (ie, parenteral fluids, oxygen, or airway support). Out of 3725 participants, 1466 (39%) were hospitalized, and 1023 out of 1466 participants (69.8%) received EBST. The use of EBST varied by site ( < .001; range 6%-99%, median 23%), but not by network ( = .2). Significant multivariable predictors and their odds ratios (ORs) were as follows: age (0.9), oxygen saturation (1.3), apnea (3.4), dehydration (3.2), nasal flaring and/or grunting (2.4), poor feeding (2.1), chest retractions (1.9), and respiratory rate (1.2). The use of pharmacotherapy and radiography varied by network and site ( < .001), with respective intersite ranges 2% to 79% and 1.6% to 81%. Compared with Australia and New Zealand, the multivariable OR for the use of pharmacotherapy in Spain and Portugal was 22.7 (95% confidence interval [CI]: 4.5-111), use in Canada was 11.5 (95% CI: 3.7-36), use in the United States was 6.8 (95% CI: 2.3-19.8), and use in the United Kingdom was 1.4 (95% CI: 0.4-4.2). Compared with United Kingdom, OR for radiography use in the United States was 4.9 (95% CI 2.0-12.2), use in Canada was 4.9 (95% CI 1.9-12.6), use in Spain and Portugal was 2.4 (95% CI 0.6-9.8), and use in Australia and New Zealand was 1.8 (95% CI 0.7-4.7). More than 30% of infants hospitalized with bronchiolitis received no EBST. The hospital site was a source of variation in all study outcomes, and the network also predicted the use of pharmacotherapy and radiography.