Background:

Bronchiolitis is the current leading cause of hospitalization in children. Based on the available literature, waste and unnecessary variation in bronchiolitis care are common. Significant work has gone into developing evidence–based guidelines for inpatient bronchiolitis management, though successful strategies for large–scale dissemination outside of academic medical centers are rarely reported.

Methods:

We formed a voluntary quality improvement collaborative called the Value in Inpatient Pediatrics Network. Our specific aim was to reduce utilization of non–evidence–based therapies in the inpatient care of bronchiolitis. Using the 2006 AAP bronchiolitis guideline as the basis for determining “unnecessary” therapy, we benchmarked the use of bronchodilators, steroids, chest radiography, chest physiotherapy, and viral testing using administrative data supplied by hospitals for the calendar years 2007 through 2010. Inclusion criteria were all non–ICU hospitalizations for bronchiolitis as the primary code at discharge (specifically including patients in observation status). Exclusion criteria were specific chronic illness codes. We then shared specific resources within the network on a voluntary basis, including protocols, scores, order sets and key bibliographies. We provided coaching and advice to participating centers when requested. We met yearly and honored high performing centers at this meeting.

Results:

A total of 17 centers completed the three active years of the project and are included in this report (Table 1). Aggregate data on 11,568 hospitalizations for bronchiolitis was analyzed. Demographics of participating centers are provided as Table 1. By 2010, the network achieved a 12% absolute decrease (95% CI, 5%–25%) in the number of patients receiving any dose of bronchodilator. We also saw a 3.4 dose per patient (95% CI, 1.4–5.8) absolute reduction in volume of beta–agonist utilized. Overall CPT usage declined 10% (95% CI, 2.6%–17.8%). Decreases in steroids, chest radiography or viral testing in the network were not statistically significant. The data were also analyzed on an institutional level for intra–institutional change. 88% of institutions achieved significant decreases in any bronchodilator usage and 80% did so for doses per patient. Direct cost savings related to decreased beta–agonist usage alone amount to $449,000.

Conclusions:

Real world effectiveness in dissemination of evidence–based guidelines may be achieved with a volunteer, peer group collaborative bridging community and academic institutions.

Table 1Characteristics of Participating Institutions