Factors Associated With Bronchiolitis Guideline Nonadherence at US Children’s Hospitals

BACKGROUND The objective with this study was to explore factors associated with nonadherence to national bronchiolitis guidelines at 52 children’s hospitals. METHODS We included patients 1 month to 2 years old with emergency department (ED) or admission encounters between January 2016 and December 2018 and bronchiolitis diagnoses in the Pediatric Health Information System database. We excluded patients with any intensive care, stay >7 days, encounters in the preceding 30 days, chronic medical conditions, croup, pneumonia, or asthma. Guideline nonadherence was defined as receiving any of 5 tests or treatments: bronchodilators, chest radiographs, systemic steroids, antibiotics, and viral testing. Nonadherence outcomes were modeled by using mixed effects logistic regression with random effects for providers and hospitals. Adjusted odds ratio (aOR) >1 indicates greater likelihood of nonadherence. RESULTS A total of 198 028 encounters were included (141 442 ED and 56 586 admission), and nonadherence was 46.1% (ED: 40.2%, admissions: 61.0%). Nonadherence increased with patient age, with both ED and hospital providers being more likely to order tests and treatments for children 12 to 24 months compared with infants 1 ot 2 months (ED: aOR, 3.39; 95% confidence interval [CI], 3.20–3.60; admissions: aOR, 2.97; CI, 2.79–3.17]). Admitted non-Hispanic Black patients were more likely than non-Hispanic white patients to receive guideline nonadherent care (aOR, 1.16; CI, 1.10–1.23), a difference driven by higher use of steroids (aOR, 1.29; CI, 1.17–1.41) and bronchodilators (aOR, 1.39; CI, 1.31–1.48). Hospital effects were prominent for viral testing in ED and admission encounters (intraclass correlation coefficient of 0.35 and 0.32, respectively). CONCLUSIONS Multiple factors are associated with national bronchiolitis guideline nonadherence.