title: Variability in inpatient management of children hospitalized with bronchiolitis.
abstract: OBJECTIVE
  To determine the variability between hospitals in 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 (2007-2010) 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 proportion of patients who received diagnostic testing (complete blood count 21-75%, chest radiograph 36-85%) and medications/interventions (bronchodilators 19-91%, systemic corticosteroids 8-44%, antibiotics 17-43%, IV placement 38-93%). 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.
authors.affiliation: Department of Pediatrics, Section of Emergency Medicine, and Center for Clinical Effectiveness, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex. Electronic address: cgmacias@texaschildrens.org.
authors.forename: Charles G
authors.initials: CG
authors.lastname: Macias
authors.affiliation: Department of Medicine, Children's Hospital Boston, Harvard Medical School, Boston, Mass.
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Mansbach
authors.affiliation: Department of Pediatrics, Rady Children's Hospital, University of California, San Diego, Calif.
authors.forename: Erin S
authors.initials: ES
authors.lastname: Fisher
authors.affiliation: Department of Pediatrics, Children's Hospital of Colorado, Denver, Colo.
authors.forename: Mark
authors.initials: M
authors.lastname: Riederer
authors.affiliation: Departments of Molecular Virology and Microbiology, and Pediatrics, Baylor College of Medicine, Houston, Tex.
authors.forename: Pedro A
authors.initials: PA
authors.lastname: Piedra
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Ashley F
authors.initials: AF
authors.lastname: Sullivan
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Janice A
authors.initials: JA
authors.lastname: Espinola
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Camargo
mesh_terms: D000305:Adrenal Cortex Hormones / Q000627:therapeutic use*; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001772:Blood Cell Count; D001988:Bronchiolitis / Q000175:diagnosis / Q000628:therapy*; D001993:Bronchodilator Agents / Q000627:therapeutic use*; D002406:Catheterization, Peripheral; D015331:Cohort Studies; D019468:Disease Management; D005260:Female; D006760:Hospitalization; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D055361:Multilevel Analysis; D010818:Practice Patterns, Physicians'; D011446:Prospective Studies; D013902:Radiography, Thoracic; D012720:Severity of Illness Index
chemical_list: D000305:Adrenal Cortex Hormones; D000900:Anti-Bacterial Agents; D001993:Bronchodilator Agents
keywords: bronchiolitis; hospitalization; intraclass correlation coefficient; quality of care; variation