Wide Institutional Variability in the Treatment of Pediatric Critical Asthma: A Multicenter Retrospective Study

Abstract

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.

25 Years of Pediatric Critical Care Medicine: An Evolving Journal

“…As an example of how such registries remain important, consider a January 2024 PCCM publication that explored the 2013 to 2021 PHIS dataset for variability in the treatment of ‘pediatric critical asthma’ (6). In April 2024, in the Annals of the American Thoracic Society , these same authors used the 2012 to 2021 VPS dataset to report the variability in use of respiratory support for pediatric critical asthma in more detail (7). Progression in questions being asked and tested across the PHIS and VPS datasets was iterative and informative.…”