Variability in Inpatient Management of Children

Hospitalized With Bronchiolitis

Charles G. Macias, MD, MPH; Jonathan M. Mansbach, MD, MPH; Erin S. Fisher, MD;
Mark Riederer, MD; Pedro A. Piedra, MD; Ashley F. Sullivan, MS, MPH;
Janice A. Espinola, MPH; Carlos A. Camargo, Jr., MD, DrPH
From the Department of Pediatrics, Section of Emergency Medicine, and Center for Clinical Effectiveness, Texas Childrens Hospital, Baylor
College of Medicine, Houston, Tex (Dr Macias); Department of Medicine, Childrens Hospital Boston, Harvard Medical School, Boston, Mass
(Dr Mansbach); Department of Pediatrics, Rady Childrens Hospital, University of California, San Diego, Calif (Dr Fisher); Department of
Pediatrics, Childrens Hospital of Colorado, Denver, Colo (Dr Riederer); Departments of Molecular Virology and Microbiology, and Pediatrics,
Baylor College of Medicine, Houston, Tex (Dr Piedra); and Department of Emergency Medicine, Massachusetts General Hospital, Harvard
Medical School, Boston, Mass (Ms Sullivan, Ms Espinola, and Dr Camargo)
The authors declare that they have no conflict of interest.
Address correspondence to Charles G. Macias, MD, MPH, 6621 Fannin St, Suite A.2210, Houston, TX 77030 (e-mail: cgmacias@
texaschildrens.org).
Received for publication February 10, 2014; accepted July 19, 2014.

ABSTRACT
OBJECTIVE: To determine the variability between hospitals in

tion of patients who received diagnostic testing (complete blood

count 2175%, chest radiograph 3685%) and medications/interventions (bronchodilators 1991%, systemic corticosteroids
844%, antibiotics 1743%, IV placement 3893%). Adjusting
for demographic and clinical patient characteristics did not
materially affect the proportion of variability attributable to hospitals (differences in ICCs with and without model adjustment
<4%).
CONCLUSIONS: Wide variations in diagnostic test utilization
and management interventions seen among children with bronchiolitis treated on the inpatient wards at 16 US hospitals were
not attributable to demographic or clinical patient characteristics. These results further support efforts to standardize care
for bronchiolitis through active quality improvement strategies.

diagnostic testing and management interventions for children

with bronchiolitis admitted to inpatient wards and identify its
association with patient characteristics.
METHODS: A prospective, multicenter (16 hospitals), multiyear (20072010) observational study of children (age <2
years) hospitalized with bronchiolitis. Outcomes included variability in diagnostic testing (complete blood count, chest radiographs) and medications or interventions (bronchodilator,
systemic corticosteroid, antibiotic, IV placement) by hospital.
A modified Respiratory Distress Severity Score was utilized
to assess severity of illness. For all outcomes, intraclass correlation coefficient (ICC) was calculated from a model to estimate
the random effects of hospital without added covariates and
compared to ICCs from a second model that adjusted for demographic and clinical patient characteristics. A second unadjusted
and adjusted model was created for age $2 months.
RESULTS: Of 2207 subjects, 1715 were identified as admitted
to inpatient wards. We observed wide variations in the propor-

KEYWORDS: bronchiolitis; intraclass correlation coefficient;

hospitalization; quality of care; variation
ACADEMIC PEDIATRICS 2015;15:6976

WHATS NEW

cause of hospitalization in infants, provides an example

of how reducing variation in practice has demonstrated
improved quality outcomes and reduced costs in pediatric
inpatient settings.4,5
An evidence base insufficient to conclusively define the
utility of chest radiographs, complete blood cell (CBC)
counts, antibiotics, or the optimal approach to delivery
of b-agonist therapy has driven expert opinion and
national consensus guideline development.68 Wide
variations in emergency department (ED) practice have
been demonstrated using clinical quality metrics or
resource utilization indicators.911 Similarly, variability
in admission, discharge decisions, and therapy have
contributed to variability in the rate of admission and
length of stay.12 Isolated efforts at minimizing variation
in these settings have demonstrated decreases in inpatient
treatment variation and improved outcomes for bronchiolitis.13 The extent of variation between hospitals and its

Variation in diagnostic testing and management has

been described for multiple disease processes. This
study demonstrates that such variation is not driven
by demographic and clinical patient characteristics,
including disease severity and fever, among children
hospitalized with bronchiolitis.

GROWING DEMANDS FOR health care infrastructures to

deliver better quality of care, and concurrently better outcomes, have dominated a national agenda, partly as a result
of the cost of health care in the United States; in particular,
national expenditures for hospital care exceeded $760
billion in 2009 and continues to rise.1 Wide variations in
practice, including variations in diagnostic testing and therapy may contribute to high costs of care2 without any increase in quality outcomes.3 Bronchiolitis, the leading
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Copyright 2015 by Academic Pediatric Association

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relationship to patient specific characteristics, including

clinical risk factors, remains uncertain.
We analyzed data from a prospective multicenter, multiyear study of more than 2000 children. We sought to determine the variability between hospitals in diagnostic testing
and management interventions for children with bronchiolitis admitted to inpatient wards. We hypothesized that
there would be wide variations in diagnostic testing and
treatments at the 16 hospitals and that these differences
would be unrelated to demographic or clinical patient characteristics, including severity of illness and fever.

METHODS
STUDY DESIGN
We conducted a prospective cohort study during the
2007 to 2010 winter seasons as part of the Multicenter
Airway Research Collaboration (MARC), a program of
the Emergency Medicine Network (EMNet) (http://www.
emnet-usa.org). The study design and methods have been
described previously.14 Briefly, 13 to 16 hospitals in 12
US states enrolled children hospitalized with bronchiolitis
over 3 years utilizing a standardized protocol of identifying
consecutive hospitalized patients. All institutions were
large urban hospitals with academic affiliations that provided a variety of specialty services/expertise for pediatric
patients but had varied census sizes and work flow infrastructures. We included all children age <2 years with an
attending physician diagnosis of bronchiolitis.
The institutional review board at all participating hospitals approved the study. The consent and data collection
forms were available in English and Spanish.
DATA COLLECTION
Investigators conducted structured interviews and chart
reviews to gather data from the preadmission evaluation
(defined as occurring in the ED, clinic or primary care visit
preceding the admission) and the clinical course on the
inpatient wards. These data were manually reviewed at
the EMNet Coordinating Center, and hospital investigators
were queried about missing data and discrepancies.
To examine the variability in inpatient care among children hospitalized for bronchiolitis, we identified all non
intensive care unit patients who were admitted to the
observation unit, inpatient ward, or stepdown unit and did
not receive an intensive care unit intervention (ie, continuous positive airway pressure or intubation); they are
referred to here as inpatients. Of 3910 eligible children
from 16 hospitals, 2207 subjects (56%) were enrolled in
the parent study, of whom 1715 (78%) were identified as in-

patients. A median number of 120 patients (interquartile

range 87130) were enrolled at each of the hospitals; no statistical difference in hospital enrollment totals was noted.
To evaluate bronchiolitis severity among participants, a
modified Respiratory Distress Severity Scores (RDSS) was
calculated with a maximum possible summed score of 8.
In contrast to the RDSS described in a previous study,15
the modified RDSS retained the categorization of retractions
and respiratory rate by age, but dichotomized wheezing and
simplified the assessment of aeration (Table 1). The initial
preadmission RDSS (rather than RDSS at other times in
the management) was utilized to account for the influence
of initial decision making by providers on the subsequent
preadmission and inpatient diagnosis and treatment.
Nasopharyngeal aspirates were collected using a standardized protocol described elsewhere.14
STATISTICAL ANALYSES
All analyses were performed by Stata 13.0 (StataCorp,
College Station, Tex). Data are presented as proportions
with 95% confidence intervals (CI), medians with ranges
or interquartile ranges, or means with 95% CIs. To assess
the variability in inpatient care, unadjusted association between study hospital and other factors were examined by
chi-square test, Fishers exact test, ANOVA, and KruskalWallis tests, as appropriate.
All P values were 2-tailed, with P < .05 considered statistically significant. Imputed values, calculated with the
Stata impute command, were used to calculate the RDSS
when 1 of the components was missing (n 192); patients
missing data for more than 1 component (n 100) were not
assigned an RDSS value. When comparing results of the
imputed RDSS variable to the nonimputed RDSS variable
(calculated from children who had complete data), there
was no material difference observed (data not shown).
Thus, all presented RDSS results were obtained using the
imputed version of the variable.
Multilevel mixed effects logistic regression models that
specify hospital-specific random effects were generated to
assess between-hospital variability with and without
adjustment for demographic and clinical patient characteristics. For each diagnostic test or management intervention, we first created a reduced model to estimate the
random effects of the hospital, evaluating the betweenhospital differences alone. A second, full model was
created for all outcomes to estimate hospital effects while
additionally adjusting for patient characteristics (demographic characteristics included were age, sex, race, insurance, and estimated median household income by zip code

Table 1. Modified Respiratory Distress Severity Score (RDSS)*

Respiratory Rate, bpm
Score
0
1
2

Age 011.9 mo

Age 1223.9 mo

Wheezing

Air Entry

Retractions

#40
4155
>55

#30
3145
>45

No
.
Yes

None
Mild
Moderate or severe

None
Mild
Moderate or severe

*Total score: 04 mild; >4 moderate to severe.

ACADEMIC PEDIATRICS

CHILDREN WITH BRONCHIOLITIS

[Esri Desktop Business Analyst, 20072010]; clinical

characteristics included were relevant comorbid conditions, parent history of asthma, history of wheeze, fever
[temperature $38 C], and RDSS [in tertiles]). All models
were repeated for an age-restricted population ($2
months) among whom clinical factors would be most relevant and least influenced by the management of illness,
including fever, in the neonate/very young infant for
whom test ordering may be more likely. The intraclass correlation coefficients (ICCs) derived from our reduced
models represent the proportion of total outcome variation
that is attributable to hospital level differences without
adjustment for patient characteristics, while the ICCs
from our full models represent the total outcome variation
that is attributable to hospital level differences after accounting for differences in demographic and clinical patient characteristics. Data were analyzed by hospital to
account for the effect of the whole local health care system
on each of the metrics.

RESULTS
Patients enrolled in the parent study (from which the
cohort of inpatients was derived) were similar in age and
gender to nonenrolled patients (P > .05).14 The median
age of 1715 inpatients was 4.4 months (interquartile range
1.98.7 months), with 26% aged less than 2 months (95%
CI 2428); 60% were male; and 60% were white (Table 2).
Less than 25% had a history of gestational age less than 37
weeks, 23% had a history of wheeze, and approximately
one-third had either one or both parents report a history
of asthma (Table 2). Among the total cohort of patients,
72% of patients were noted to have respiratory syncytial virus, while 25% had human rhinovirus (Table 2).
When examining diagnostic testing, a CBC was obtained in 40% (95% CI 3842) and a chest radiograph
in 67% (95% CI 6469) of children during their hospitalization. Medications were also used variably. Most patients received bronchodilators before admission (66%;
95% CI 6468), but less than half received bronchodilators as inpatients (47%; 95% CI 4550). Of note, 18%
(95% CI 1620) of patients received only 1 treatment
(presumably a trial of bronchodilator therapy) throughout
their preadmission and inpatient stay. Nebulized hypertonic saline was used in 10 of 16 hospitals in study years
2 and 3; 5% of patients (95% CI 47) received more than 1
hypertonic saline treatment. Preadmission systemic corticosteroids and antibiotics were provided in 18% (95% CI
1620) and 22% (95% CI 2024), while on the inpatient
wards systemic corticosteroids and antibiotics were provided in 19% (95% CI 1720) and 31% (95% CI 2934)
of all patients, respectively.
The association between severity of illness (assessed using
the composite RDSS) and diagnostic testing, medication use,
and interventions was evaluated (Table 3). Across the 16
study hospitals, the mean RDSS was 4.1 (95% CI 4.04.2).
The proportion of patients at each hospital who had a
diagnostic test, medication and/or intervention spanned a
broad range; visual associations of patterns of utilization

71

Table 2. Demographic and Clinical Characteristics of Children

Admitted to Inpatient Ward With Bronchiolitis

Characteristic
Age in mo, median (IQR)
Age <2 mo, n
Male
Race
White
Black
Other or missing
Hispanic
Insurance
Private
Public
None
Gestational age <37 wk
History of wheeze
Parent history of asthma
Used inhaled bronchodilator in
week before admission
Used any corticosteroids
in week before admission
Relevant comorbid
conditions
RSV
HRV
Fever*
RDSS, mean

Proportion of
Children (95% CI) Hospital Site
(n 1,715)
Range (n 16)
4.4 (1.98.7)
26 (2428)
60 (5762)

2.66.5
1646
4966

60 (5863)
26 (2428)
14 (1216)
37 (3539)

1397
058
340
397

31 (2833)
65 (6367)
4 (35)
23 (2125)
23 (2125)
32 (2934)
39 (3741)

165
3297
112
1829
834
1242
2659

16 (1418)

625

21 (1923)

1115

72 (7074)
25 (2327)
28 (2631)
4.1 (4.04.2)

5886
1138
1546
3.24.8

CI indicates confidence interval; IQR, interquartile range; RSV,

respiratory syncytial virus; HRV, human rhinovirus; and RDSS, respiratory distress severity score.
*Fever defined as temperature $100.4 F.

among hospitals are demonstrated in the Figure. The proportion of children at the different hospitals that had the
acquisition of CBC or chest radiograph demonstrated
wide variability with ranges of 21% to 75% and 36% to
85% respectively. The widest ranges in proportion for
each management intervention outcome was noted in the
inpatient use of bronchodilators (1991%), with inpatient
systemic corticosteroid use ranging from 8% to 44%, inpatient antibiotic use at 17% to 43%, and the placement of an
IV in any setting at 38% to 93%.
The ICC, representing the percentage of variability due
to hospital differences, was similar for the unadjusted
versus adjusted models for all ages, and similar in the
age restricted models (Table 4). Regardless of adjustment
for patient demographic or clinical characteristics, antibiotic use (both preadmission and inpatient) consistently exhibited the lowest percentage of variability attributable to
hospital differences, while inpatient bronchodilator use
demonstrated the highest percentage. Adjusting for demographic and clinical patient characteristics increased the
ICC for inpatient bronchodilator use (unadjusted 17.5%,
adjusted 20.6%), but only by 3.1%, representing a minimal
effect of patient characteristics on the large hospital variability described for its use. No material difference in the
models resulted from restricting the bronchodilator therapy
outcome from any bronchodilator use to those receiving
>1 treatment (trial use median of 15%, hospital range 3
29%) (Table 4). Hypertonic saline was not entered into

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Table 3. Associations Between Diagnostic Testing/Management

Interventions and Severity of Bronchiolitis
Diagnostic Test or
Management
Intervention

Mean
RDSS
(Imputed)

95% CI
Lower

Upper

CBC performed
No
4.2
4.1
4.3
Yes
3.9
3.8
4.1
Chest x-ray performed
No
4.0
3.9
4.2
Yes
4.1
4.0
4.3
Nebulized bronchodilators provided (before admission)
No
3.0
2.9
3.2
Yes
4.6
4.5
4.7
Nebulized bronchodilators provided (inpatient)
No
3.7
3.5
3.8
Yes
4.6
4.4
4.7
Corticosteroids (before admission)
No
4.0
3.9
4.1
Yes
4.7
4.5
4.9
Corticosteroids (inpatient)
No
3.9
3.8
4.0
Yes
4.9
4.7
5.1
Antibiotics (before admission)
No
4.2
4.1
4.3
Yes
3.8
3.6
4.0
Antibiotics (inpatient)
No
4.1
4.0
4.2
Yes
4.1
3.9
4.3
IV placement
No
4.0
3.8
4.1
Yes
4.2
4.0
4.3

P
.005

.25

<.001
<.001
<.001
<.001

.01

.81

.08

RDSS indicates respiratory distress severity score; CI, confidence interval; and CBC, complete blood count.

the models because its use was uncommon. When restricting the models to age $2 months, no ICC was altered by
>3%; thus, no material difference was noted in the unadjusted and adjusted models (Table 4).

DISCUSSION
In this large multiyear prospective study of children
treated for bronchiolitis on the inpatient wards at 16 hospitals, we found wide variation in the utilization of diagnostic
tests (eg, CBC, chest radiograph), medications, or interventions (eg, bronchodilator, antibiotics or systemic corticosteroids, IV placement). This variability was not
explained by demographic or clinical patient differences,
including fever or severity of illness. This patient cohort
(RDSS mean 4.1) is similar in severity to the patient population admitted for bronchiolitis in which the RDSS was
described.15 Given the existence of widely accepted guidelines for care (eg, American Academy of Pediatrics),8 directing strategies at minimizing variation for diagnosis
and management of bronchiolitis likely will help reduce
the variation seen between hospitals.
The current literature does not recommend diagnostic
testing for patients with bronchiolitis, but few data support
the impact of testing on patient outcomes and thus on quality of care.7 There is little evidence to support the routine
use of bronchodilators or corticosteroids.1619 Indeed,
sufficient evidence and consensus exists against the

routine use of both diagnostic tests and management

interventions in bronchiolitis described in this study such
that they have become quality of care metrics with higher
utilization representing lower quality of care (decreased
effectiveness, efficiency, safety of care).9,10,20,21
Much of the continued use of bronchodilators and corticosteroids may emanate from similarities in the signs and
symptoms between bronchiolitis and asthma. ED-based
diagnosis for children with lower respiratory infection
symptoms has been noted to be hospital specific, with practitioners in some hospitals being more likely to diagnose
bronchiolitis, symptoms (eg, cough/wheeze), or asthma.22
One could surmise that ED based diagnoses are also likely
to influence care decisions into the inpatient setting.
Indeed, the preadmission rate of corticosteroid use in our
study was essentially equal to the inpatient use across the
aggregated group of patients. Additionally, an institutional
bias for testing is also suggested in our data in which relatively similar patterns of utilization at each of the hospitals
are seen in CBC and chest radiograph utilization (Figure).
However, medication use and interventions patterns of utilization appear less similar (Figure). In the absence of a criterion standard for diagnosing bronchiolitis, better
strategies for uptake of consensus definitions for diagnosing bronchiolitis would help reduce unnecessary testing
and management interventions.
A study utilizing the Pediatric Health Information System (PHIS) found significant variation in diagnostic tests
and treatment approaches between 30 US hospitals after
controlling for potential confounders.23 As the study used
retrospective, cross-sectional data, causal inferences could
not be made and associations with patient-specific clinical
factors could not be established. In the present study, we
have demonstrated that even after adjusting for demographic and clinical factors, including severity of illness
and fever, wide variations between hospitals persisted.
Among the inpatient population of children with bronchiolitis, the PHIS study reported proportions of patients with
utilization of chest radiographs, bronchodilators, systemic
corticosteroids and antibiotics as 72%, 57%, 25% and 45%
respectively23; in our population these proportions were
67%, 47%, 19% and 31% respectively. Thus, we report
similar but consistently lower proportions across all of
the tracked utilization metrics. Wide ranges in utilization
between hospitals are demonstrated in both cohorts. Given
that our sampling was conducted from 2007 to 2010, this
decrease is consistent with recent data from another national sampling utilizing the Kids Inpatient Database
(Healthcare Cost and Utilization Project) which demonstrated trends for decreased utilization of chest radiographs
and IV antibiotics in hospitalized children with bronchiolitis from 2000 to 2009.24 Similarly, another more recent
study of the PHIS database from 2004 to 2012 demonstrated rates of utilization of chest radiographs, bronchodilators, systemic corticosteroids and antibiotics as 52%,
58%, 16%, and 33% respectively.25 The causes of these
trends are unclear but may represent more widely accepted
professional society guidelines25 or a growing attention to
quality in childrens care based on improvements in

ACADEMIC PEDIATRICS

CHILDREN WITH BRONCHIOLITIS

73

Figure. Diagnostic tests and medical management/interventions by hospital. Each graph demonstrates the proportion of patients at each site
that received the diagnostic test (first row) or was managed with a medication and/or intervention (second row) and the 95% confidence interval around that proportion.

regional systems of health care evidenced by an increasing

proportion of hospitalizations in childrens hospitals.24
The impact of care variation has been explored by
studies attempting to discern its association with outcome
measures (eg, length of stay and cost). Evidence suggests
that variations in clinical care delivery processes for bronchiolitis, including the threshold for oxygen supplementation and criteria for admission and discharge have a
significant impact on length of stay.12,13 However,
multiple factors effect length of hospital stay for children
with bronchiolitis.14 Nonetheless, the aggregate effect of
these variations in delivery of care coupled with the varia-

tion in diagnostic testing and management seen in this

study highlights inefficiency and ineffectiveness within
systems of care.
Active implementation of quality improvement strategies can decrease this variation in practice. A PHIS study
described an association between increased seasonal inpatient bronchiolitis prevalence and decreased utilization of
corticosteroids and radiographs (noted in both winter and
summer months); this is consistent with other volumeoutcome studies which suggest that during periods of
high prevalence, hospitals might function more like
specialty hospitals and achieve better outcomes.26

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Table 4. Intersite Variation With and Without Adjustment for Childrens Characteristics

Characteristic
CBC performed (anywhere)
Chest x-ray performed (anywhere)
Any nebulized bronchodilators
provided (before admission)
Any nebulized bronchodilators
provided (inpatient)
>1 nebulized bronchodilator
provided (anywhere)
IV received (anywhere)
Any corticosteroids (before
admission)
Any corticosteroids (inpatient)
Antibiotics (before admission)
Antibiotics (inpatient)

All Ages (n 1715)

Age $2 mo (n 1272)

ICC (95% CI)

ICC (95% CI)

Adjusted for Site

Random Effects
Only

Adjusted for
Site Random
Effects and Patient
Characteristics*

Adjusted for Site

Random Effects
Only

Adjusted for Site

Random Effects and
Patient Characteristics*

9.6% (4.519.1)
9.5% (4.519.0)
9.2% (4.318.5)

11.2% (5.321.9)
10.4% (4.821.0)
10.2% (4.621.0)

11.7% (5.523.0)
9.7% (4.519.8)
11.1% (5.022.7)

13.9% (6.626.7)
9.9% (4.420.8)
9.0% (3.720.4)

17.5% (9.031.5)

20.6% (10.636.2)

17.9% (8.932.6)

18.6% (9.134.3)

16.7% (8.430.4)

20.1% (10.235.6)

18.8% (9.434.1)

19.7% (9.636.0)

14.1% (6.527.7)
5.5% (2.113.7)

16.4% (7.731.5)
5.1% (1.813.8)

15.2% (6.830.6)
5.8% (2.214.3)

16.4% (7.233.1)
4.7% (1.613.2)

10.0% (4.520.8)
3.4% (1.29.6)
2.8% (1.07.6)

12.7% (5.725.9)
2.4% (0.69.4)
1.8% (0.47.3)

11.9% (5.524.0)
3.3% (1.010.6)
2.0% (0.57.3)

13.2% (5.827.0)
2.5% (0.510.7)
1.1% (0.19.8)

ICC indicates intraclass correlation coefficient; CI, confidence interval; and CBC, complete blood count.
*Age, sex, race, insurance, median household income by zip code; major relevant comorbid medical disorder; parent history of asthma;
history of wheeze; fever, respiratory distress severity score (tertiles).

Specifically, improved clinician knowledge of higher seasonal community prevalence, utilizing inpatient bronchiolitis prevalence as a proxy, may decrease unnecessary tests
and treatments.26 In general, this builds a case for bringing
evidence based decision support to the clinician to reduce
wide variations in practice.
Other evidence to support minimization of diagnostic
testing and management interventions exist.27 Strategies
based on improving adherence to guidelines have been
demonstrated to improve outcomes28 (in reducing antibiotic overuse,4 corticosteroid and IV fluid administration,29
bronchodilator use,13 and hospital readmissions29). Clinical pathways, which are bedside interpretations of guidelines for care, have been demonstrated to decrease both
antibiotic and corticosteroid use for patients with bronchiolitis.4 Strategies specifically targeted to inpatient clinicians
that include clinical pathway integration can improve outcomes of care.28 Specifically, computerized point-of-care
decision support to physicians caring for patients with
bronchiolitis has improved overutilization of resources in
inpatient settings (ie, diagnostic testing and treatments)
and represents an effective strategy for systematic integration of evidence based practice.30,31 Long-standing presence of guideline implementation (representing a culture
for acceptance of evidence based standardization of care)
and online accessibility of a written guideline were associated with reduced diagnostic testing and treatment for
bronchiolitis among 33 childrens hospitals associated
with PHIS.32 The study was limited by administrative
data sources and thus was not linked to clinical patient data.
Quality collaboratives are institutional collaborations
that implement improvement strategies and are driven by
a shared baseline or bundled baseline interventions. One
bronchiolitis collaborative demonstrated improvement at
7 hospitals with a 9% decrease in the proportion of infants
receiving a bronchodilator treatment (with a relative

decrease of 44% in corticosteroid use) after implementation of the guideline and coupled with an educationbased implementation strategy; mean length of stay
decreased by 7%.33 Inpatient bronchodilator use and chest
physiotherapy also have been decreased through provision
of data (benchmarking) within a voluntary pediatric hospitalist bronchiolitis collaborative.20 Active strategies in
quality improvement of bronchiolitis care can overcome
assumptions that patient characteristics, including clinical
factors, are driving known variations in practice.
Prior studies have demonstrated reductions in cost
through pathway implementation for standardization of
bronchiolitis care in ED settings34 or across the continuum
of care.4 Comprehensive multidisciplinary institutional
guideline development with multifaceted implementation
strategies have demonstrated reductions in resource utilization and other improvements in quality metrics.31,32 In
aggregate, this suggests that opportunities exist to reduce
the $8,530 mean hospital charge per case nationally
(2009).24
There are several potential limitations of this study. In
describing practice patterns across several US hospitals,
generalizability to outpatient care delivery hospitals or to
community hospitals may be limited as the participating
hospitals in our study were large urban teaching hospitals.
Moreover, comparisons of the changing characteristics of
the health care delivery infrastructures and work flows
within or between hospitals were outside of the scope of
this study, limiting our ability to define associations between infrastructure characteristics and variation. Another
potential limitation is the utilization of a clinical diagnosis
of bronchiolitis by the attending physician as a requirement
for enrollment may have limited enrollment of children
with more equivocal cases of bronchiolitis, or included
children who have other lower respiratory infections or
conditions. Multiple viral etiologies may manifest as

ACADEMIC PEDIATRICS

bronchiolitis, thus highlighting the need for better evidence

to both diagnose and stage the disease. In the current study,
with 72% of the patients having confirmed respiratory syncytial virus and 25% with human rhinovirus, there is
suggestion that the physicians clinical diagnosis is consistent with expected viral etiologies. Nonetheless, real-world
settings reflect common elements of uncertainty for the
clinician, given the absence of a criterion standard for diagnosing bronchiolitis and provide more reason for why standardization of diagnosis and management should be
integrated into clinical infrastructures.
Another limitation to our study was that it was not designed to determine the causes for the variation; reasons
for testing and treatment were not queried. However, we
demonstrated that such variation was not attributable to patient demographic or clinical characteristics in a full and
age restricted population ($2 months) among which clinical decisions are less driven by age-related risk for infection. In addition to demographic factors, our models were
adjusted for relevant clinical factors which might have
influenced clinical decision making at the time of the study
(ie, significant comorbid conditions, parent history of
asthma, history of wheeze, fever, RDSS). We were limited
in our ability to include all possible clinical factors. Despite
emerging literature during and after our study period
describing other clinical risk factors that could drive
concern for increased risk of apnea, respiratory failure,
infection or other complications (eg, birth weight, previous
apnea, preadmission oxygen saturation, maternal smoking
during pregnancy, difficulty breathing initiating <1 day
before admission, viral etiology, ED visit in the past
week), the implications of these factors on everyday decisions to escalate testing or treatment strategies is unclear
and thus were not considered in our models.3537
Our study was not designed to consider clinical decision
support (either its existence or enhancement over time)
within the work flow at the hospitals, regardless of whether
through clinical guidelines, pathways, quality improvement collaborative participation, or embedded decision
support within the electronic medical record. Hospitals
with large resource consumption and presumably greater
amounts of waste may benefit most from standardization
of care through quality improvement efforts.
By utilizing prospective clinical data at 16 hospitals, we
have described wide variations in utilization of diagnostic
tests and management interventions for children hospitalized on the inpatient ward with bronchiolitis. These variations are not attributable to either demographic or clinical
patient characteristics, including severity of illness, but
likely represent institutional factors. These data highlight
the need to standardize diagnosis and management strategies across institutions to minimize resource consumption
while improving quality of care and thus patient outcomes.

ACKNOWLEDGMENTS
Principal investigators at the 16 participating hospitals in MARC-30
are as follows: Besh Barcega, MD (Loma Linda University Childrens
Hospital, Loma Linda, Calif); John Cheng, MD and Carlos Delgado,
MD (Childrens Healthcare of Atlanta at Egleston, Atlanta, Ga); Dorothy

CHILDREN WITH BRONCHIOLITIS

75

Damore, MD and Nikhil Shah, MD (New York Presbyterian Hospital,

New York, NY); Haitham Haddad, MD (Rainbow Babies & Childrens
Hospital, Cleveland, Ohio); Paul Hain, MD and Mark Riederer, MD
(Monroe Carell Jr. Childrens Hospital at Vanderbilt, Nashville, Tenn);
Frank LoVecchio, DO (Maricopa Medical Center, Phoenix, Ariz);
Charles Macias, MD, MPH (Texas Childrens Hospital, Houston, Tex);
Jonathan Mansbach, MD, MPH (Boston Childrens Hospital, Boston,
Mass); Eugene Mowad, MD (Akron Childrens Hospital, Akron,
Ohio); Brian Pate, MD (Childrens Mercy Hospital & Clinics, Kansas
City, Mo); M. Jason Sanders, MD (Childrens Memorial Hermann Hospital, Houston, Tex); Alan Schroeder, MD (Santa Clara Valley Medical
Center, San Jose, Calif); Michelle Stevenson, MD, MS (Kosair Childrens Hospital, Louisville, Ky); Erin Stucky Fisher, MD (Rady Childrens Hospital, San Diego, Calif); Stephen Teach, MD, MPH
(Childrens National Medical Center, Washington, DC); Lisa Zaoutis,
MD (Childrens Hospital of Philadelphia, Philadelphia, Pa).
This study was supported by the grants U01 AI-67693 and K23 AI77801 from the National Institutes of Health (Bethesda, MD). The content
of this manuscript is solely the responsibility of the authors and does not
necessarily represent the official views of the National Institute of Allergy
and Infectious Diseases or the National Institutes of Health. We thank the
Multicenter Airway Research Collaboration-30 investigators for their
ongoing dedication to bronchiolitis research. No conflicts of interest
regarding this work have been reported by any of the investigators.

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