WHAT'S KNOWN ON THIS SUBJECT: With the publication of evidence-based guidelines for asthma, bronchiolitis, and pneumonia, numerous efforts have been made to standardize and improve the quality of care. However, despite these guidelines, variation in care exists. WHAT THIS STUDY ADDS:This study establishes clinically achievable benchmarks of care for asthma, bronchiolitis, and pneumonia. Using a published method for achievable benchmarks of care, we calculated average utilization among the high-performers, which can serve as achievable goals for local quality improvement. abstract BACKGROUND AND OBJECTIVES: Asthma, pneumonia, and bronchiolitis are the leading causes of admission for pediatric patients; however, the lack of accepted benchmarks is a barrier to quality improvement efforts. Using data from children hospitalized with asthma, bronchiolitis, or pneumonia, the goals of this study were to: (1) measure the 2012 performance of freestanding children' s hospitals using clinical quality indicators; and (2) construct achievable benchmarks of care (ABCs) for the clinical quality indicators. METHODS:This study was a cross-sectional trial using the Pediatric Health Information System database. Patient inclusions varied according to diagnosis: asthma (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 493.0-493.92) from 2 to 18 years of age; bronchiolitis ) from 2 months to 2 years of age; and pneumonia (ICD-9-CM codes 480-486, 487.0) from 2 months to 18 years of age. ABC methods use the best-performing hospitals that comprise at least 10% of the total population to compute the benchmark. RESULTS:Encounters from 42 hospitals included: asthma, 22 186; bronchiolitis, 14 882; and pneumonia, 12 983. Asthma ABCs include: chest radiograph utilization, 24.5%; antibiotic administration, 6.6%; and ipratropium bromide use .2 days, 0%. Bronchiolitis ABCs include: chest radiograph utilization, 32.4%; viral testing, 0.6%; antibiotic administration, 18.5%; bronchodilator use .2 days, 11.4%; and steroid use, 6.4%. Pneumonia ABCs include: complete blood cell count utilization, 28.8%; viral testing, 1.5%; initial narrow-spectrum antibiotic use, 60.7%; erythrocyte sedimentation rate, 3.5%; and C-reactive protein, 0.1%. CONCLUSIONS:We report achievable benchmarks for inpatient care for asthma, bronchiolitis, and pneumonia. The establishment of national benchmarks will drive improvement at individual hospitals. Clinical practice guidelines (CPGs) are systematically developed statements that can guide providers in decisionmaking. 1 CPGs are intended to reduce variation, which in turn is expected to lower costs and improve outcomes. Despite the availability of national CPGs for 3 of the most common pediatric inpatient conditions (asthma, bronchiolitis, and pneumonia), wide variation in their management continues across US hospitals, leading to excess resource utilization and cost of care. 2-7 Improvements have been modest at best; 1 possible reason is that although the guidelines make recomm...

Dr Ralston conceptualized the project and codirected its implementation, coordinated and critically reviewed all analyses, and drafted the initial manuscript; Dr Garber conceptualized the project and codirected its implementation and critically reviewed and revised the manuscript; Ms Rice-Conboy coordinated all aspects of project design, implementation, and data collection and critically reviewed and revised the manuscript; Drs Mussman, Shadman, and Walley provided project leadership and content, performed a portion of the analysis, and critically reviewed and revised the manuscript; Ms Nichols performed the analyses, prepared all tables and fi gures, and critically reviewed the manuscript; and all authors approved the fi nal manuscript as submitted.

BACKGROUND Hospitalizations of children with medical complexity (CMC) account for one‐half of hospital days in children, with lengths of stays (LOS) that are typically longer than those for children without medical complexity. The objective was to assess the impact of, risk factors for, and variation across children's hospitals regarding long LOS (≥10 days) hospitalizations in CMC. METHODS A retrospective study of 954,018 CMC hospitalizations, excluding admissions for neonatal and cancer care, during 2013 to 2014 in 44 children's hospitals. CMC were identified using 3M's Clinical Risk Group categories 6, 7, and 9, representing children with multiple and/or catastrophic chronic conditions. Multivariable regression was used to identify demographic and clinical characteristics associated with LOS ≥10 days. Hospital‐level risk‐adjusted rates of long LOS generated from these models were compared using a covariance test of the hospitals' random effect. RESULTS Among CMC, LOS ≥10 days accounted for 14.9% (n = 142,082) of all admissions and 61.8% ($13.7 billion) of hospital costs. The characteristics most strongly associated with LOS ≥10 days were use of intensive care unit (ICU) (odds ratio [OR]: 3.5, 95% confidence interval [CI]: 3.4‐3.5), respiratory complex chronic condition (OR: 2.7, 95% CI: 2.6‐2.7), and transfer from another medical facility (OR: 2.1, 95% CI: 2.0‐2.1). After adjusting for severity, there was significant (P < 0.001) variation in the prevalence of LOS ≥10 days for CMC across children's hospitals (range, 10.3%–21.8%). CONCLUSIONS Long hospitalizations for CMC are costly. Their prevalence varies significantly by type of chronic condition and across children's hospitals. Efforts to reduce hospital costs in CMC might benefit from a focus on prolonged LOS. Journal of Hospital Medicine 2016;11:750–756. © 2016 Society of Hospital Medicine

Collaboration between ED and IP units was associated with a decreased use of unnecessary tests and therapies in bronchiolitis; top performers used few unnecessary tests or treatments.