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Practice Variation in Acute Bronchiolitis: A Pediatric Emergency Research Networks Study
Suzanne Schuh1,2,3, Franz E Babl4, Stuart R Dalziel5
1Division of Paediatric Emergency Medicine and.
Insights
Hospitalized infants with bronchiolitis often do not receive evidence-based supportive therapies (EBSTs). Significant variation exists in EBST delivery across hospital sites, highlighting a need for standardized care in pediatric bronchiolitis management.
Area of Science:
- Pediatrics
- Infectious Diseases
- Respiratory Medicine
Background:
- Bronchiolitis is a common viral respiratory infection in infants.
- Existing studies have not adequately characterized the use of evidence-based supportive therapies (EBSTs) in hospitalized infants with bronchiolitis.
- Variations in care delivery may impact patient outcomes.
Purpose of the Study:
- To assess intersite and internetwork variation in the administration of EBSTs for hospitalized infants diagnosed with bronchiolitis.
- To identify patient characteristics associated with receiving EBSTs.
- To examine the influence of hospital site and research network on treatment variations.
Main Methods:
- Retrospective cohort study involving 3725 infants under 12 months with bronchiolitis across 38 pediatric emergency departments in international research networks.
- Primary outcome: receipt of at least one EBST (parenteral fluids, oxygen, or airway support) during hospitalization.
- Multivariable analysis to identify predictors of EBST use and variations by site and network.
Main Results:
- Of 1466 hospitalized infants, 69.8% received EBSTs, with significant variation by hospital site (range 6%-99%).
- Patient factors like apnea, dehydration, and respiratory distress predicted EBST use.
- Pharmacotherapy and radiography use varied significantly by site and network, with notable differences between countries.
Conclusions:
- Over 30% of hospitalized infants with bronchiolitis did not receive EBSTs.
- Hospital site is a major determinant of care variation for all studied outcomes.
- Research networks also influenced the use of pharmacotherapy and radiography, suggesting a need for standardized treatment protocols.
Background And Objectives:
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.
Methods:
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).
Results:
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 (P < .001; range 6%-99%, median 23%), but not by network (P = .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 (P < .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).
Conclusions:
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.
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