Variability in inpatient management of children hospitalized with bronchiolitis

Acad Pediatr. Jan-Feb 2015;15(1):69-76. doi: 10.1016/j.acap.2014.07.005. Epub 2014 Nov 8.


Objective: To determine the variability between hospitals in diagnostic testing and management interventions for children with bronchiolitis admitted to inpatient wards and identify its association with patient characteristics.

Methods: A prospective, multicenter (16 hospitals), multiyear (2007-2010) observational study of children (age <2 years) hospitalized with bronchiolitis. Outcomes included variability in diagnostic testing (complete blood count, chest radiographs) and medications or interventions (bronchodilator, systemic corticosteroid, antibiotic, IV placement) by hospital. A modified Respiratory Distress Severity Score was utilized to assess severity of illness. For all outcomes, intraclass correlation coefficient (ICC) was calculated from a model to estimate the random effects of hospital without added covariates and compared to ICCs from a second model that adjusted for demographic and clinical patient characteristics. A second unadjusted and adjusted model was created for age ≥ 2 months.

Results: Of 2207 subjects, 1715 were identified as admitted to inpatient wards. We observed wide variations in the proportion of patients who received diagnostic testing (complete blood count 21-75%, chest radiograph 36-85%) and medications/interventions (bronchodilators 19-91%, systemic corticosteroids 8-44%, antibiotics 17-43%, IV placement 38-93%). Adjusting for demographic and clinical patient characteristics did not materially affect the proportion of variability attributable to hospitals (differences in ICCs with and without model adjustment <4%).

Conclusions: Wide variations in diagnostic test utilization and management interventions seen among children with bronchiolitis treated on the inpatient wards at 16 US hospitals were not attributable to demographic or clinical patient characteristics. These results further support efforts to standardize care for bronchiolitis through active quality improvement strategies.

Keywords: bronchiolitis; hospitalization; intraclass correlation coefficient; quality of care; variation.

Publication types

  • Multicenter Study
  • Observational Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adrenal Cortex Hormones / therapeutic use*
  • Anti-Bacterial Agents / therapeutic use*
  • Blood Cell Count
  • Bronchiolitis / diagnosis
  • Bronchiolitis / therapy*
  • Bronchodilator Agents / therapeutic use*
  • Catheterization, Peripheral
  • Cohort Studies
  • Disease Management
  • Female
  • Hospitalization*
  • Humans
  • Infant
  • Infant, Newborn
  • Male
  • Multilevel Analysis
  • Practice Patterns, Physicians'*
  • Prospective Studies
  • Radiography, Thoracic
  • Severity of Illness Index


  • Adrenal Cortex Hormones
  • Anti-Bacterial Agents
  • Bronchodilator Agents