Variation in the management of infants hospitalized for bronchiolitis persists after the 2006 American Academy of Pediatrics bronchiolitis guidelines

J Pediatr. 2014 Oct;165(4):786-92.e1. doi: 10.1016/j.jpeds.2014.05.057. Epub 2014 Jul 9.


Objective: To describe variation across US pediatric hospitals in the utilization of resources not recommended for routine use by the American Academy of Pediatrics guideline for infants hospitalized with bronchiolitis and to examine the association between resource utilization and disposition outcomes.

Study design: We conducted a cross-sectional study of infants ≤12 months hospitalized for bronchiolitis from 2007-2012 at 42 hospitals contributing data to the Pediatric Health Information System. Patients with asthma were excluded. The primary outcome was hospital-level variation in utilization of 5 resources not recommended for routine use: albuterol, racemic epinephrine, corticosteroids, chest radiography, and antibiotics. We also examined the association of resource utilization with length of stay (LOS) and readmission.

Results: In total, 64,994 hospitalizations were analyzed. After adjustment for patient characteristics, albuterol (median, 52.4%; range, 3.5%-81%), racemic epinephrine (20.1%; 0.6%-78.8%), and chest radiography (54.9%; 24.1%-76.7%) had the greatest variation across hospitals. Utilization of albuterol, racemic epinephrine, and antibiotics did not change significantly over time compared with small decreases in corticosteroid (3.3%) and chest radiography (8.6%) use over the study period. Utilization of each resource was significantly associated with increased LOS without concomitant decreased odds of readmission.

Conclusions: Substantial use and variation in 5 resources not recommended for routine use by the American Academy of Pediatrics bronchiolitis guideline persists with increased utilization associated with increased LOS without the benefit of decreased readmission. Future work should focus on developing processes that can be widely disseminated and easily implemented to minimize unwarranted practice variation when evidence and guidelines exist.

Publication types

  • Multicenter Study

MeSH terms

  • Adrenal Cortex Hormones / therapeutic use
  • Albuterol / therapeutic use
  • Bronchiolitis / therapy*
  • Bronchodilator Agents / therapeutic use
  • Cohort Studies
  • Cross-Sectional Studies
  • Epinephrine / chemistry
  • Epinephrine / therapeutic use
  • Evidence-Based Medicine
  • Female
  • Guideline Adherence*
  • Hospitalization
  • Hospitals, Pediatric
  • Humans
  • Infant
  • Infant, Newborn
  • Length of Stay
  • Male
  • Patient Readmission
  • Pediatrics / standards*
  • Practice Guidelines as Topic
  • Practice Patterns, Physicians'
  • Radiography, Thoracic
  • Regression Analysis
  • Societies, Medical
  • Time Factors
  • Treatment Outcome
  • United States


  • Adrenal Cortex Hormones
  • Bronchodilator Agents
  • Albuterol
  • Epinephrine