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Wide Institutional Variability in the Treatment of Pediatric Critical Asthma: A Multicenter Retrospective Study
Colin M Rogerson1, Alexander H Hogan2, Briana Waldo3
1Division of Pediatric Critical Care Medicine, Indiana University School of Medicine, Indianapolis, IN.
Insights
Adjunctive asthma therapies for severe asthma in children vary widely across hospitals. This variability in treatments did not impact hospital length of stay or pediatric intensive care unit (PICU) admission rates.
Area of Science:
- Pediatric critical care medicine
- Respiratory medicine
- Health services research
Background:
- Status asthmaticus in children often requires treatments beyond systemic corticosteroids and inhaled beta-agonists.
- There is a lack of national guidelines for asthma management in the pediatric intensive care unit (PICU).
Purpose of the Study:
- To evaluate institutional variability in the use of adjunctive asthma therapies for pediatric patients.
- To assess the association between the use of these therapies and length of stay (LOS) and PICU admission rates.
Main Methods:
- Multicenter retrospective cohort study.
- Utilized administrative data from the Pediatric Health Information Systems (PHIS) database (2013-2021).
- Included 213,506 inpatient asthma encounters for children aged 2-18 years, with 29,026 PICU encounters from 39 institutions.
Main Results:
- Significant institutional variability observed in the number and types of adjunctive therapies used per PICU encounter.
- The median number of adjunctive therapies per encounter ranged from 0.6 to 2.5 across institutions.
- No significant association found between the average number of adjunctive therapies used and hospital LOS or the percentage of asthma admissions requiring PICU care.
Conclusions:
- Wide variation exists in adjunctive therapy use for status asthmaticus among children's hospitals.
- Current adjunctive therapy practices are not demonstrably linked to improved hospital LOS or reduced PICU admission rates.
- Standardizing care with evidence-based guidelines presents an opportunity to optimize outcomes and reduce costs.
Objectives:
Children with status asthmaticus refractory to first-line therapies of systemic corticosteroids and inhaled beta-agonists often receive additional treatments. Because there are no national guidelines on the use of asthma therapies in the PICU, we sought to evaluate institutional variability in the use of adjunctive asthma treatments and associations with length of stay (LOS) and PICU use.
Design:
Multicenter retrospective cohort study.
Setting:
Administrative data from the Pediatric Health Information Systems (PHIS) database.
Patients:
All inpatients 2-18 years old were admitted to a PHIS hospital between 2013 and 2021 with a diagnostic code for asthma.
Interventions:
None.
Measurements And Main Results:
This study included 213,506 inpatient encounters for asthma, of which 29,026 patient encounters included care in a PICU from 39 institutions. Among these PICU encounters, large variability was seen across institutions in both the number of adjunctive asthma therapies used per encounter (min: 0.6, median: 1.7, max: 2.5, p < 0.01) and types of adjunctive asthma therapies (aminophylline, ipratropium, magnesium, epinephrine, and terbutaline) used. The center-level median hospital LOS ranged from 1 (interquartile range [IQR]: 1, 3) to 4 (3, 6) days. Among all the 213,506 inpatient encounters for asthma, the range of asthma admissions that resulted in PICU admission varied between centers from 5.2% to 47.3%. The average number of adjunctive therapies used per institution was not significantly associated with hospital LOS ( p = 0.81) nor the percentage of encounters with PICU admission ( p = 0.47).
Conclusions:
Use of adjunctive therapies for status asthmaticus varies widely among large children's hospitals and was not associated with hospital LOS or the percentage of encounters with PICU admission. Wide variance presents an opportunity for standardizing care with evidence-based guidelines to optimize outcomes and decrease adverse treatment effects and hospital costs.
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