Practice Variation among Pediatric Emergency Departments in the Treatment of Bronchiolitis

Plint, Amy C.; Johnson, David W.; Wiebe, Natasha; Bulloch, Blake; Pusic, Martin; Joubert, Gary; Pianosi, Paul; Turner, Troy; Thompson, Graham C.; Klassen, Terry P

doi:10.1111/j.1553-2712.2004.tb01452.x

Cited by 60 publications

(68 citation statements)

References 36 publications

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“…Such undesired variability may decrease system reliability (introducing avoidable opportunity for error), 26 and lead to under-use of needed therapies as well as overuse of unnecessary therapies. 1 Our work extends prior research that has identified wide variation in patterns of hospital admission, use of hospital resources, and processes of inpatient care, [27][28][29][30][31][32] by documenting reported variation in the use of common inpatient therapies. Rates of hospital admission may vary by as much as 7-fold across regions.…”

Section: Discussionsupporting

confidence: 63%

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Variation in pediatric hospitalists' use of proven and unproven therapies: A study from the Pediatric Research in Inpatient Settings (PRIS) network

Landrigan

Conway

Stucky

et al. 2008

Journal of Hospital Medicine

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BACKGROUND:Undesirable practice variation remains a major concern with the quality of the healthcare system. While care in pediatric hospitalist systems has been demonstrated to be efficient, neither the quality of care nor determinants of variation in pediatric hospitalist systems are well understood.OBJECTIVE:To measure variation in pediatric hospitalists' reported use of common inpatient therapies, and to test the hypothesis that variation in reported use of proven therapies is lower than variation in reported use of unproven therapies.DESIGN AND MEASUREMENTS:We conducted a survey of pediatric hospitalists in the US and Canada. Respondents reported their frequency of using 14 therapies in the management of common conditions. Each therapy was determined to be of proven or unproven effectiveness using published critical appraisals. Variation in reported use of proven and unproven therapies was compared.RESULTS:67% (213/320) of surveyed individuals participated. Little variability existed in reported use of albuterol and corticosteroids in asthma (4‐6% of respondents reported not often using them) and systemic dexamethasone in bronchiolitis (12% of respondents reported using it more than rarely). Moderate to high variation existed in reported use of all other therapies studied. Variation in reported use of proven therapies was significantly less than variation in reported use of unproven therapies (15.5 ± 12.5% vs. 44.6 ± 20.5%).CONCLUSIONS:Substantial variation exists in hospitalists' reported management of common pediatric conditions. Variation is significantly lower for strongly evidence‐based therapies. To decrease undesirable variation in care, a stronger evidence base for inpatient pediatric care must be built. Journal of Hospital Medicine 2008;3:292–298. © 2008 Society of Hospital Medicine.

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Section: Discussionsupporting

confidence: 63%

“…Our study also supports the hypothesis that variation in care may be driven by gaps in knowledge. 32 Among hospitalists, we found the strength of the evidence base to be a major determinant of reported variability.…”

Section: Discussionmentioning

confidence: 94%

Variation in pediatric hospitalists' use of proven and unproven therapies: A study from the Pediatric Research in Inpatient Settings (PRIS) network

Landrigan

Conway

Stucky

et al. 2008

Journal of Hospital Medicine

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“…63% of bronchiolitis patients have seen their primary care physicians during their illness prior to the ED visit [15]. The existing models for predicting hospital admission and ICU admission for bronchiolitis patients are mainly developed for the ED setting.…”

Section: Predicting Optimal Disposition In the Primary Care Settingmentioning

confidence: 99%

“…At present, many bronchiolitis management decisions are made subjectively [2,10]. This leads to significant practice variation, as is reflected in variable admission rates and use of specific therapies among different hospitals and physicians [1,4,[10][11][12][13][14][15][16][17][18][19][20]. Observed practice variation is not explained by differences in patient severity and has little impact on outcomes, but has a significant impact on healthcare resource usage [17].…”

Section: Introductionmentioning

confidence: 99%

A systematic review of predictive modeling for bronchiolitis

Luo

Nkoy

Gesteland

et al. 2014

International Journal of Medical Informatics

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Purpose: Bronchiolitis is the most common cause of illness leading to hospitalization in young children. At present, many bronchiolitis management decisions are made subjectively, leading to significant practice variation among hospitals and physicians caring for children with bronchiolitis. To standardize care for bronchiolitis, researchers have proposed various models to predict the disease course to help determine a proper management plan. This paper reviews the existing state of the art of predictive modeling for bronchiolitis. Predictive modeling for respiratory syncytial virus (RSV) infection is covered whenever appropriate, as RSV accounts for about 70% of bronchiolitis cases.Methods: A systematic review was conducted through a PubMed search up to April 25, 2014. The literature on predictive modeling for bronchiolitis was retrieved using a comprehensive search query, which was developed through an iterative process.Search results were limited to human subjects, the English language, and children (birth-18 years). Results:The literature search returned 2,312 references in total. After manual review, 168 of these references were determined to be relevant and are discussed in this paper. We identify several limitations and open problems in predictive modeling for bronchiolitis, and provide some preliminary thoughts on how to address them, with the hope to stimulate future research in this domain. Conclusions:Many problems remain open in predictive modeling for bronchiolitis. Future studies will need to address them to achieve optimal predictive models.

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“…Although the mortality rate is low in high-income countries, bronchiolitis is an important illness worldwide because of the frequency that affected infants require medical care and hospitalization [1][2][3] and because of the burden on patients and families resulting from the length and severity of symptoms. 4 The number of hospital admissions for bronchiolitis has doubled over the last 10 to 15 years in both Canada and the United States. 1,2 In 1996, ϳ16% of all US hospital admissions in the first year of life were for bronchiolitis, 1 and in 1998, annual hospital charges for respiratory syncytial virus-associated bronchiolitis were estimated at $365 to $691 million.…”

mentioning

confidence: 99%

Cost-effectiveness of Epinephrine and Dexamethasone in Children With Bronchiolitis

Sumner

Coyle²,

Mitton

et al. 2010

Pediatrics

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WHAT'S KNOWN ON THIS SUBJECT:Despite the large economic burden of bronchiolitis, there have been no economic evaluations of the effectiveness of intervention with bronchodilators or steroids. WHAT THIS STUDY ADDS:Economic analysis reveals that treatment infants with bronchiolitis with combined epinephrine and dexamethasone results in the lowest health care system and societal costs. abstract OBJECTIVE: Using data from the Canadian Bronchiolitis Epinephrine Steroid Trial we assessed the cost-effectiveness of treatments with epinephrine and dexamethasone for infants between 6 weeks and 12 months of age with bronchiolitis. METHODS:An economic evaluation was conducted from both the societal and health care system perspectives including all costs during 22 days after enrollment. The effectiveness of therapy was measured by the duration of symptoms of feeding problems, sleeping problems, coughing, and noisy breathing. Comparators were nebulized epinephrine plus oral dexamethasone, nebulized epinephrine alone, oral dexamethasone alone, and no active treatment. Uncertainty around estimates was assessed through nonparametric bootstrapping. RESULTS:The combination of nebulized epinephrine plus oral dexamethasone was dominant over the other 3 comparators in that it was both the most effective and least costly. Average societal costs were $1115 (95% credible interval [CI]: 919 -1325) for the combination therapy, $1210 (95% CI: 1004 -1441) for no active treatment, $1322 (95% CI: 1093-1571) for epinephrine alone, and $1360 (95% CI: 1124 -1624) for dexamethasone alone. The average time to curtailment of all symptoms was 12.1 days (95% CI: 11-13) for the combination therapy, 12.7 days (95% CI: 12-13) for no active treatment, 13.0 days (95% CI: 12-14) for epinephrine alone, and 12.6 days (95% CI: 12-13) for dexamethasone alone. CONCLUSION:Treating infants with bronchiolitis with a combination of nebulized epinephrine plus oral dexamethasone is the most costeffective treatment option, because it is the most effective in controlling symptoms and is associated with the least costs. Pediatrics 2010; 126:623-631

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Practice Variation among Pediatric Emergency Departments in the Treatment of Bronchiolitis

Cited by 60 publications

References 36 publications

Variation in pediatric hospitalists' use of proven and unproven therapies: A study from the Pediatric Research in Inpatient Settings (PRIS) network

Variation in pediatric hospitalists' use of proven and unproven therapies: A study from the Pediatric Research in Inpatient Settings (PRIS) network

A systematic review of predictive modeling for bronchiolitis

Cost-effectiveness of Epinephrine and Dexamethasone in Children With Bronchiolitis

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