bronchiolitis management before and after the aap guidelines

DOI: 10.1542/peds.2013-2005; originally published online December 2, 2013;Pediatrics

Kavita Parikh, Matthew Hall and Stephen J. TeachBronchiolitis Management Before and After the AAP Guidelines

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Bronchiolitis Management Before and After the AAPGuidelines

WHATS KNOWN ON THIS SUBJECT: Bronchiolitis is a leadingcause of hospitalization for children, yet variability in itsmanagement persists. To promote evidence-based care, theAmerican Academy of Pediatrics published practice guidelines in2006 that advocate primarily supportive care for this self-limiteddisease.

WHAT THIS STUDY ADDS: Since publication of the guidelines in2006, few studies have evaluated their impact on diagnostictesting and treatment. This study documents positive changes inresource use among hospitalized patients with bronchiolitis overan 8-year period.

abstractBACKGROUND AND OBJECTIVES: Evidence-based practice guidelinesfor bronchiolitis management published by the American Academy ofPediatrics in 2006 recommend supportive care with limited diagnostictesting and treatment. We sought to determine the impact of theseguidelines on the treatment of hospitalized children.

METHODS: We analyzed data on inpatients with bronchiolitis aged 1 to24 months from the Pediatric Health Information System, an adminis-trative billing database, from November 1, 2004 to March 31, 2012. Wecompared trends in use of diagnostic and treatment resources beforeand after the publication of the guidelines by using segmented timeseries.

RESULTS: A total of 41 pediatric hospitals contributed data to yield 130262 patients; 58% were male, and 59% were publicly insured. Medianage was 4.0 months (interquartile range, 29). Unadjusted analysisshowed improvement in utilization rates before and after guidelinesfor diagnostic tests and for medications; however, there was no de-creased use of antibiotics. A segmented regression analysis alsodemonstrated differences in rates of change before and after guide-lines, with signicant improvement for chest radiography, steroids,and bronchodilators (P , .0001).

CONCLUSIONS: In a nationally representative cohort of pediatric hos-pitals, publication of the 2006 American Academy of Pediatrics bron-chiolitis guidelines was associated with signicant reductions in theuse of diagnostic and therapeutic resources. Pediatrics 2014;133:17

AUTHORS: Kavita Parikh, MD,a Matthew Hall, PhD,b andStephen J. Teach, MD, MPHc

aDivision of Hospitalist Medicine, and cDivision of EmergencyMedicine, Childrens National Medical Center, Washington, Districtof Columbia; and bChildrens Hospital Association, Overland Park,Kansas

KEY WORDSbronchiolitis, guidelines, resource utilization

ABBREVIATIONSAAPAmerican Academy of PediatricsCBCcomplete blood cellCXRchest radiographyEDemergency departmentNHAMCSNational Hospital Ambulatory Medical Care SurveyPHISPediatric Health Information SystemRSVrespiratory syncytial virus

Dr Parikh conceptualized the study, conducted the analysis, anddrafted the manuscript; Dr Hall gathered the data andconducted the analysis and manuscript preparation; and DrTeach helped with study conceptualization and manuscriptpreparation.

www.pediatrics.org/cgi/doi/10.1542/peds.2013-2005

doi:10.1542/peds.2013-2005

Accepted for publication Oct 1, 2013

Address correspondence to Kavita Parikh, MD, Division ofHospitalist Medicine, 111 Michigan Ave NW, Washington, DC 20010.E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright 2014 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno nancial relationships relevant to this article to disclose.

FUNDING: Supported by the Young Investigator Award throughthe Academic Pediatric Association.

POTENTIAL CONFLICT OF INTEREST: The authors have indicatedthey have no potential conicts of interest to disclose.

PEDIATRICS Volume 133, Number 1, January 2014 1

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Bronchiolitis is a common respira-tory illness that predominantly affectsinfants and young children and ac-counts for $543 million annually inhospitalization charges.1 The mainstayof treatment of bronchiolitis is sup-portive care, with good evidence thatmost specic treatments are in-effective, including bronchodilators,corticosteroids, antibiotics, and chestphysiotherapy.29 Nonetheless, signi-cant variability persists in the care forpatients with bronchiolitis,1012 poten-tially generating unnecessary andcostly resource use. With increasingconcern of the quality and cost ofhealth care delivered in the UnitedStates, there has been a focus onachieving higher-quality outcomes perdollar spent on health care.13

In an effort to achieve higher quality ofcare, numerousevidence-basedclinicalpractice guidelines have been pub-lished to assist clinicians in makingdecisions about appropriate care inspecic clinical circumstances.14 In2006, the American Academy of Pedi-atrics (AAP),15 with the support of theAgency for Healthcare Research andQuality published a systematic reviewof the diagnosis and treatment ofbronchiolitis titled Diagnosis andManagement of Bronchiolitis. Thisclinical practice guideline emphasizessupportive care with oxygen and hy-dration (when necessary) and recom-mends limited use of diagnostic testingand medications, including broncho-dilators, corticosteroids, and anti-biotics.15

Weaimed todetermine the impactof the2006AAPbronchiolitis guidelines on thecare of children hospitalized withbronchiolitis by comparing preguide-line and postguideline use of diagnostictests and treatments. We hypothesizedthat the use of diagnostic testing andmedications would decrease after thepublication of the guidelines.

METHODS

Data Source

The study is a retrospective, observa-tional cohort study using the PediatricHealth Information System (PHIS) da-tabase (Childrens Hospital Association,Overland Park, Kansas). The PHIS da-tabase contains deidentied adminis-trative data, detailing demographics,diagnostics, procedures, and phar-macy billing, from 41 freestandingtertiary care childrens hospitals. Thisdatabase accounts for 20% of all an-nual pediatric hospitalizations in theUnited States. Data quality is ensuredthrough a joint effort between theChildrens Hospital Association andparticipating hospitals.

Patient Population

PHIS data were used to evaluatehospital-level resource use for children28 days to 730 days (2 years) of agedischarged November 1, 2004 to March30, 2012. Our goal was to identify un-complicated bronchiolitis hospitaliza-tions involving previously healthychildren.All initialadmissionsofpatientswere included if they met both of thefollowing criteria:

1. All Patient Rened Diagnosis-Related Groups version 24, Bron-chiolitis and RSV Pneumonia (code138)

2. Primary diagnosis of acute bron-chiolitis (International Classica-tion of Diseases, Ninth Revisioncode 466.11 or 466.19).

Exclusion criteria included presence ofa chronic complex condition,16 a billingcharge for mechanical ventilation,a length of stay .10 days, and anyreadmission during the study period.According to Feudtner et al,16 re-spiratory chronic complex conditionsdo not include asthma or reactive air-way disease but include respiratorymalformations, cystic brosis, andbronchopulmonary dysplasia or chronic

lung disease. Subsequent bronchiolitisreadmissions were excluded from thedata set because of the assumption thatthese readmissions may be manageddifferently, so we included only the rstadmission.

Relationship of GuidelinePublication and Resource Use

The measured exposure was the dis-charge date of the admission forbronchiolitis. For the unadjusted anal-ysis, patients were grouped into 3cohorts based on guideline publicationin October 2006: preguideline (Novem-ber 2004 to March 2005), postguidelineearly (November 2007 to March 2008),and postguideline late (November 2011to March 2012). These time periodswere selected for the unadjustedanalysis because they represent 3bronchiolitis seasons, before and afterguideline publication; the 2006 to 2007seasonwasnot includedbecause this isthe year the guideline was publishedand was a period of distribution andassimilation. For the adjusted seg-mented regression analysis, publica-tionof theguidelines, October 2006,wasconsidered the event point.

Themeasured outcomeswere the ratesof diagnostic and treatment resourceuse as determined from billing data.The diagnostic tests were completeblood cell (CBC) count, chest radiog-raphy (CXR), and respiratory syncytialvirus (RSV) testing. The treatment mo-dalities were bronchodilator usage(including any bronchodilator and daysof bronchodilator), corticosteroid us-age, and antibiotic usage.

Statistical Analysis

Because of their nonnormal distri-butions, continuous factors weresummarized with medians and inter-quartile ranges and then comparedwith MannWhitney tests. Categoricalfactors were summarized by usingfrequencies with percentages and then

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compared with x2 tests for groupedanalysis. Segmented regression analy-sis was used to control for hospitalclustering and secular trends in vari-ation. Monthly rates of resource utili-zation were used in the segmentedregression analysis. All statisticalanalyses were performed with SASversion 9.3 (SAS Institute, Inc, Cary, NC),and P values ,.001 were consideredstatistically signicant. Signicance of,.001 was used to ensure strength ofthe relationship given the large sam-ple. Institutional review board approvalwas obtained from the Childrens Na-tionalMedical Center review committee.

RESULTS

There were 159 697 hospital admis-sions in the PHIS database meetingstudy inclusion criteria (Fig 1). Ofthese, 29 435 met exclusion criteria.

Characteristics of the 130 262 patientsin thenal sample are included in Table 1.The median age was 4 months (inter-quartile range, 29months); a majoritywere male (58%) and had public in-surance (59%).

This analysis included a total of 37 907patients divided into the 3 time cohorts:preguideline, n = 9949; postguidelineearly, n = 13 741; and postguideline late,n = 14 217. In this analysis, there wasminimal change between the pre-guideline and postguideline earlygroups but a decrease in resource usein the postguideline late group (Fig 2).There were statistically signicantdecreases in use of diagnostic testsincluding CBC counts, CXRs, and RSVtesting (P , .001). In regard to treat-ment modalities, there was a statisti-cally signicant decrease in usage ofcorticosteroids and bronchodilators

(P, .001); the strength of the decreasefor antibiotic use was not statisticallysignicant by our predened criterion(P = .007). Duration of bronchodilatordays was also analyzed, and althoughthe median days of use remained con-stant (1 day), the interquartile rangewas lower (01 days) in the post-guideline late group than in the pre-guideline and postguideline earlygroups (02 days) (P , .001).

Segmented regression analysis wasdone to account for hospital clus-tering and to compare rates of changebefore and after the publication of theguidelines in 2006 (Figs 3 and 4). Thisanalysis includes the whole studypopulation (n = 130 262) over theentire study period (November 2004 toMarch 2012) and calculates the rate ofchange over the specied period byusing October 2006, year of guideline

FIGURE 1Study population ow diagram. ICD-9-CM, International Classication of Diseases, Ninth Revision, Clinical Modication.

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publication, as the event point. In theadjusted analysis, the monthly rate ofchange for CXR use before guidelinepublication was +0.39, and afterguideline publication, the monthly rate

of change for CXR use was20.52 (P,.0001 for comparison). This representsan increasing rate of use before theguidelines were published, comparedwith a signicantly different and de-creasing rate of use afterward. A sim-ilar trend was noted for CBC count use(preguideline rate of change = 0.14,postguideline rate of change = 20.26,P = .0061) and treatment options, in-cluding corticosteroids (preguidelinerate of change = 0.42, postguidelinerate of change =20.48, P, .0001) andbronchodilators (preguideline rate ofchange = 0.40, postguideline rate ofchange = 20.46, P , .0001). Thechange in CBC count use was not sta-tistically signicant by the predened

criteria of P , .001, but it does ap-proach signicance. Although therewas a trend toward similar ndingswith antibiotic usage (preguidelinerate of change = 0.10, postguidelinerate of change = 20.16, P = .08), thischange was not statistically signicant.Counter to the results of the un-adjusted analysis, RSV testing use wasactually decreasing before guidelinepublication and increasing afterguideline publication (preguidelinerate of change = 20.5, postguidelinerate of change = 0.23, P = .047); how-ever, this relationship is not as statis-tically strong as the other factors.

To analyze results with a longer pre-guideline period, additional analysiswas run by using the same inclusionand exclusion criteria over a longertime interval, from January 2002 toDecember 2012. Over this study period,only 26 hospitals contributed data forthe entire time period, yielding a nalstudy population of 112 637. Segmentedregression analysis revealed similarresults, with statistically signicantdecreased use of CXR and bronchodi-lators; however, although they weredecreasing, rates of CBC count andsteroid use were no longer signicant.

DISCUSSION

For hospitalized patients with bron-chiolitis aged 1 to 24 months, we showa temporal association between publi-cation of the 2006 AAP bronchiolitisguidelines and a decrease in resourceuse, including both diagnostic tests(CBC count and CXR) and therapies(corticosteroids and bronchodilators).We did not see a strong change in uti-lization patterns for RSV testing andantibiotic use. It is possible that hos-pitals continued to use RSV testing tocohort patients for admission, whichmay explain why we did not see a sta-tistically signicant decrease in usage.Although we cannot demonstrate acausal relationship, this reduction of

FIGURE 2Diagnostic and treatment utilization over 3 time periods from 41 hospitals (n = 37 907).

TABLE 1 Demographic Information forStudy Population (n = 130 262)

Age, median months(interquartile range)

4 (29)

Male, % 58Race or ethnicity, %

White 21Black 11Hispanic 23Asian 1Other 44

Payer, %Government 59Private 27Other 14


diagnostic testing and treatment re-sources for bronchiolitis after guide-line publication is striking and may bereducing costs associated with thiscommon respiratory illness.

A recent publication evaluated the im-pact of the AAP guidelines on manage-ment of bronchiolitis in the emergencydepartment (ED).17 By using the Na-tional Hospital Ambulatory MedicalCare Survey (NHAMCS), a nationallyrepresentative sample of ED visits, theauthors found a decrease in diagnosticimaging with CXR but no decreasein nonrecommended therapies, suchas bronchodilators, corticosteroids,and antibiotics. In contrast, our studyshowed a reduction of diagnostictests, both CXR and CBC count, andnonrecommended medications. This

discrepancy may reect the differ-ences in the NHAMCS and PHIS data-bases. NHAMCS includes ED encountersfrom a diversity of hospitals, includinggeneral ED and childrens facilities,whereas PHIS captures only encoun-ters at childrens hospitals. In the EDstudy, when the data were stratied byED type, there was reduction in the useof CXRs, steroids, and antibiotics inchildrens facilities after the guidelinespublication but no reduction in bron-chodilators. This may suggest betteradoption of national guidelines atchildrens hospitals compared withgeneral hospitals. In addition, the dif-ference in the ED patients comparedwith the admitted patients may reectthe training differences between EDclinical staff (eg, physician assistants

and nonpediatric trained ED clinicians)and pediatric hospitalists.

Although this study seeks only toevaluate the impact of the nationalguidelines, some studies suggest thatlocal clinical practice guidelines arewhat drive change at the local level.Local guidelines have been reportedto be effective in reducing theuse of diagnostic testing and non-recommendedmedicationuseinpatientswith other respiratory illnesses, such aspneumonia.18 Another factor that hasbeen shown to drive adherence to theevidence-based diagnostic and treat-ment options for bronchiolitis for inpa-tients is hospitalist care compared withnonhospitalist care.19 In a retrospectivechart review of children admitted to 2different academic centers, researchers

FIGURE 3Time series analysis for diagnostic testing over 41 hospitals fromNovember 2004 toMarch 2012 (n = 130 262). A, CBC utilization: Preguideline slope is 0.14, andPostguideline slope is 20.26, P = .0061; B, CXR utilization: Preguideline slope is 0.40, and Postguideline slope is 20.52, P , .0001*; C, RSV utilization: Pre-guideline slope is 20.50, and Postguideline slope is 0.23, P = .047. *P , .001, implying statistical signicance.

FIGURE 4Time series analysis for medication use over 41 hospitals fromNovember 2004 to March 2012 (n = 130 262). A, Bronchodilator utilization: Preguideline slope is0.40, and Postguideline slope is20.46, P, .0001*; B, Steroid utilization: Preguideline slope is 0.42, and Postguideline slope is20.48, P, .0001*; C, Antibioticutilization: Preguideline slope is 0.10, and Postguideline slope is 20.16, P = .082. *P , .001, implying statistical signicance.

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found that hospitalists were more likelyto discontinue bronchodilator, cortico-steroid, and antibiotic use than non-hospitalists.19 These results are similarto those of another study, which useda national survey administered to hos-pitalists and community pediatriciansand found that hospitalists were signi-cantly more likely to report rarely ornever using therapies of unproven ben-et for bronchiolitis, namely levalbuteroland steroid therapy (both inhaled andoral).12 Overall, local clinical practiceguidelines and hospitalist care havebeen shown to increase adherence tobronchiolitis guidelines and to increaseguideline adherence in a diversity ofhospitals throughout the country.

This study had several limitations. First,it used an administrative and billingdatabase, which did not include de-tailed clinical information related to theencounter. The establishment of ourpatient sample was based strictly ondiagnosis and procedure codes. Forexample, we included children from 1month to 2 years of age because of theguideline parameters, and it is possiblethat as children approached 2 years ofage, we included patients with reactiveairway disease or asthma. Further-more, although we saw a decrease intheuseofsteroidsandbronchodilators,it is possible that there was a greatereffect in the younger children, and wewill be evaluating this in future analysis.In addition, we cannot exclude thepossibility that specic tests or thera-pies were used for reasons notaddressed by the guidelines. For ex-ample, we do not know which PHIS

hospitals continued to use RSV testingto cohort patients. Second, the PHISdatabase includes only freestandingchildrens hospitals and does not re-ect practice patterns of non-PHIShospitals, namely community hospi-tals. More than 70% of infants andtoddlers presenting with bronchiolitisare seen at community hospitals, andtherefore this study evaluated practicepatterns for a minority of total inpa-tients. Third, although there was a de-crease in resource use after thepublication of the AAP guidelines, weare unable to determine a causal re-lationship. However, by using a seg-mented regression analysis, we areable to account for hospital clusteringand to evaluate change in utilizationpatterns by evaluating monthly ratesof use. Although it cannot establisha causal relationship, this analysisstrengthens the association of im-provement with guideline publication.Fourth, this study did not evaluateother factors or cointerventions thatmay have contributed to the changes inresource use, such as hospital-basedclinical practice guidelines or ordersets, professional training of the pro-vider, or the region of the hospital.

Finally, 2 of our measured outcomes(bronchodilator and antibiotic use)present unique limitations. The AAPguidelines recommend initiating a trialof bronchodilators and discontinuinguse if there is no benet. In ouranalysis,we tried to account for this limitation byincorporating a measure of broncho-dilator duration in days. In addition,although antibiotics are not recom-

mended for the treatment of bron-chiolitis, there are comorbid bacterialillnesses, such as otitis media andurinary tract infection, for which anti-biotics are needed. Our study does notaccount for appropriate antibiotic us-age in patients with bronchiolitis anda concomitant bacterial infection.

CONCLUSIONS

TheAAPs publication of its 2006 evidence-based guidelines for bronchiolitis wasassociated with a reduction of nonevidence-based diagnostic testing andmedication use for inpatients in a repre-sentative sample of childrens hospitals.These trends may demonstrate a benetof nationally developed guidelines to re-duce variations in care and unnecessarycosts. However, future studies shouldfocus on factors associated with imple-mentation and adherence, and shouldinclude a greater diversity of hospitals.

ACKNOWLEDGMENTSDr Parikh is a recipient of the Young In-vestigatorAward fromtheAcademicPe-diatric Association. This research wassupported by an Academic Pediatric As-sociation Young Investigator Awardsupported by The Aetna Foundation,anational foundationbased inHartford,CT that supports projects to promotewellness, health, and access to high-quality health care for everyone. Theviews presented here are those of theauthor and not necessarily of the AetnaFoundation, its directors, ofcers, orstaff.

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DOI: 10.1542/peds.2013-2005; originally published online December 2, 2013;Pediatrics

Kavita Parikh, Matthew Hall and Stephen J. TeachBronchiolitis Management Before and After the AAP Guidelines

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