Hospital “Report Cards”: Variation in the Management of Bronchiolitis
Christakis DA, Cowan CA, Garrison MM, Molteni R, Marcuse E, Zerr DM. Variation in Inpatient Diagnostic Testing and Management of Bronchiolitis. Pediatrics. 2005;115:878-4.
Bronchiolitis remains 1 of the most common causes of hospitalization in children within the first 2 years of life. In this analysis, the authors conducted a large retrospective descriptive study of infants who were admitted with bronchiolitis to children’s hospitals across the United States. The study examined the variability in length of stay (LOS), diagnostic testing, medications used, and readmission rates. The authors reviewed data on a total of 17,397 infants younger than 1 year of age. Information was obtained from the Pediatric Health Information System, which includes demographic and diagnostic data on 36 freestanding, noncompeting children’s hospitals. The authors found significant and wide variation in LOS, readmission rates, treatment approaches, and use of diagnostic tests for inpatient management of bronchiolitis.
Results indicated that 72% of patients received chest radiographs, 45% received antibiotics, and 25% received systemic steroids. The mean LOS varied considerably across hospitals, with a range of 2.40–3.90 days. The use of antibiotics varied from 28% to 62%, and the use of chest radiographs varied from 38% to 89%. There was also significant difference in readmission rates, which varied from 0% to 2.7%. The variation between hospitals remained a significant contributor even after controlling for multiple potential confounding factors.
Decreasing LOS and unnecessary medication and test utilization is supportive of pediatric patient safety initiatives. The authors suggest that chest radiographs may be leading to unnecessary use of antibiotics due to presumptive treatment based on nonspecific findings. In addition, the authors hypothesize that increased virologic testing may be cost-effective if it leads to decreased use of antibiotics.
The study concludes that there are considerable, unexplained variations that exist in the inpatient management of bronchiolitis. Development of national guidelines and controlled trials of new therapies and different approaches are indicated. Hospitals need to direct resources at analyzing and improving their inpatient care by implementing a more evidence-based approach to management of this common problem.
Maternal Group B Streptococcal Positivity: Risk factor or not?
Puopolo KM, Madoff LC, Eichenwald EC. Early-onset group B streptococcal disease in the era of maternal screening. Pediatrics. 2005;115:1240-6.
Despite implementation of intrapartum antibiotic prophylaxis (IAP) based on maternal screening for group B streptococcus (GBS) colonization, cases of early-onset neonatal GBS disease (EOGBS) continue to occur with significant morbidity and mortality. Researchers at the Brigham and Woman’s Hospital in Boston, MA devised this retrospective analysis to determine which attributes of maternal screening, provision of IAP, or evaluation of newborns for sepsis might influence the persistence of EOGBS cases. A retrospective review of all cases of culture proven EOGBS between 1997 and 2003 identified 25 cases of EOGBS among the 67,260 live births, for an overall incidence of 0.37 per 1000 live births. The incidence in infants of very low birth weight was 3.3 cases per 1,000 live births. Among the mothers of term infants with EOGBS, 14 of 17 (82%) had been screened GBS negative; 1 was GBS unknown. Eight of these 14 GBS negative mothers had at least 1 intrapartum risk factor for neonatal sepsis but did not receive IAP. The authors hypothesize that the negative GBS status in these cases may have provided a false sense of reassurance to obstetricians.
Ten of the 17 term infants were evaluated for sepsis due to clinical signs of illness, while the remaining infants were evaluated based on intrapartum risk factors alone. Interestingly, the retrospective analysis demonstrated that 5 of the 25 bacterial isolates were resistant to clindamycin and/or erythromycin, with another 5 isolates partially resistant to 1 or both of these medications. One case of EOGBS disease was found in the child of a penicillin-allergic mother who received clindamycin for IAP. This article highlights the importance of reviewing intrapartum risk factors other than GBS colonization—i.e., delivery at <37 weeks’ gestation,