Bronchiolitis is the leading cause of hospitalization for infants in the United States, costs more than $500 million annually, and has seen a 30% increase ($1.34 billion to $1.73 billion) in related hospital charges from 2000 to 2009.¹³ Almost all children <2 years old are infected with respiratory syncytial virus, the most common cause of bronchiolitis, with 40% developing clinically recognizable bronchiolitis and 2% becoming hospitalized with severe bronchiolitis.[4, 5] Current American Academy of Pediatrics (AAP) guidelines state that routine use of bronchodilators, corticosteroids, and chest x‐rays is not recommended, and supportive care is strongly encouraged.[6] However, a lack of consensus among clinicians persists regarding bronchiolitis management.[7, 8, 9, 10] Although minority children and those with a lower socioeconomic status (SES) in the United States are more likely to present with bronchiolitis to the emergency department (ED) and be subsequently admitted when compared to the general population,[11, 12, 13] to our knowledge, no study has yet examined if race/ethnicity is independently associated with differences in the presentation and management of severe bronchiolitis (ie, bronchiolitis causing hospitalization). Although a prior bronchiolitis‐related study reported that Hispanic children had a longer ED length of stay (LOS) than non‐Hispanic white (NHW) and non‐Hispanic black (NHB) children,[14] other studies concluded that race/ethnicity were not predictors of intensive care unit (ICU) admission or unscheduled healthcare visits post‐ED discharge.[15, 16]

Determining if race/ethnicity is independently associated with certain bronchiolitis management tendencies has implications from both a health disparities standpoint (ie, unequal care based on race/ethnicity) and from a clinical perspective (ie, the potential of certain practices, such as clinical pathways, to increase the likelihood of equitable treatment). To address this knowledge gap, we examined prospective data from a multicenter study designed to evaluate multiple factors related to bronchiolitis hospitalization.

METHODS

RESULTS

Of the 2130 subjects included in this analysis, 818 (38%) were NHW, 511 (24%) were NHB, and 801 (38%) were Hispanic. The median age for children was 4.0 months (IQR, 1.88.5 months), and 60% were male. Most children were publicly insured (65%), 31% had private insurance, and approximately 4% had no insurance. The median household income defined by patient ZIP code was $51,810 (IQR, $39,916$66,272), and nearly all children (97%) had a primary care provider (PCP). Approximately 21% of all children had relevant comorbidities and 17% of children were enrolled from the ICU. Overall, the median LOS was 2 days (IQR, 14 days).

The unadjusted associations between race/ethnicity and other demographic and historical characteristics are shown in Table 1. NHB and Hispanic children were more likely to have public insurance and less likely to have relevant major comorbidities when compared to NHW children. With regard to care received the week before hospitalization, NHW children were more likely to have visited their PCP, taken corticosteroids and/or antibiotics, and were least likely to have visited an ED when compared to NHB and Hispanic children.

The unadjusted associations between race/ethnicity and clinical characteristics at preadmission visit and hospital admission are shown in Table 2. RDSS values were calculated for 2130 children; 1,752 (82%) RDSS values contained all 4 components. Of those requiring imputed values, 234 (11%) were missing 1 component, and 139 (7%) were missing more than 1 component. Per RDSS scores, NHB children presented with a more severe case of bronchiolitis when compared to NHW and Hispanic children. During admission, minority children were more likely to receive nebulized albuterol and less likely to visit the ICU. NHB children received the least inpatient laboratory testing and were least likely to receive chest x‐rays during hospital admission among all groups.

Discharge treatment and outcomes at 1‐week follow‐up are shown in Table 3. A total of 1771 patients (83%) were reached by telephone. No statistically significant differences between racial/ethnic groups were found regarding hospital discharge on corticosteroids and likelihood of bronchiolitis‐related relapse.

Given the large potential for confounding regarding our initial findings, we examined multivariable‐adjusted associations of race/ethnicity and bronchiolitis management (Table 4). Receiving albuterol during the preadmission visit and chest x‐rays during hospitalization remained significantly associated with race/ethnicity in adjusted analyses, as NHB children were most likely to receive albuterol during the preadmission visit but least likely to receive chest x‐rays during hospitalization. Several outcomes with statistically significant differences found during unadjusted analyses (eg, chest x‐rays at preadmission visit, albuterol during hospitalization, CPAP/emntubation use, ICU admission, and LOS) were not independently associated with race/ethnicity in multivariable models. By contrast, adjusted analyses revealed Hispanic children as significantly more likely to be discharged on inhaled corticosteroids when compared to NHW and NHB children; this association had borderline statistical significance (P=0.08) in the unadjusted analysis. Last, we observed no significant racial/ethnic differences with respect to corticosteroids given at preadmission visit or hospitalization as well as no differences regarding bronchiolitis‐related relapse in either unadjusted or adjusted analyses.

DISCUSSION

It is unclear if management and treatment differences found in children with severe bronchiolitis are associated with race/ethnicity. We sought to determine if such differences exist by analyzing data from a prospective multicenter cohort study. Differences in management and treatment are discussed in the context of AAP guidelines, as they are widely used in clinical practice.

The RDSS was used to help assess severity of illness across race/ethnicity. NHB children had the highest RDSS score (ie, most severe bronchiolitis presentation) compared to NHW and Hispanic children. The reason for this difference in severity is unclear, but a potential explanation may be that minority communities lack access to care and as a result delay care and treatment for respiratory disease until care seems absolutely necessary.[19] Indeed, in our sample, minority children were less likely to visit their PCP and take corticosteroids the week before hospitalization when compared with NHW children. Our finding runs counter to a similar study by Boudreaux et al. that found no association between race/ethnicity and the clinical presentation of children with acute asthma during the preadmission setting.[20] The more severe bronchiolitis presentation among NHB children may have suggested that these children would require a longer hospital LOS (3 days). However, our multivariable analysis found no difference in LOS across racial/ethnic groups. This LOS finding is intriguing given previous studies suggesting that minorities, of diverse ages and with diverse diagnoses, were more likely to have a shorter LOS (as well as less likely to be admitted to the ICU with a similar diagnosis) when compared to nonminorities.[21, 22] Additionally, because our study sampled 16 sites, variation in clinical judgment and pediatric ICU protocol may have also played a role.[23]

Our findings also shed light on how differences in bronchiolitis management relate to AAP guidelines. According to the AAP, corticosteroid medications should not be used routinely in the management of bronchiolitis. Despite this recommendation, previous reports indicate that up to 60% of infants with severe bronchiolitis receive corticosteroid therapy.[24, 25] Our finding that Hispanic children with severe bronchiolitis were most likely to be discharged on inhaled corticosteroids is potentially concerning, as it exposes a subset of children to treatment that is not recommended. On the other hand, given the increased risk of future asthma in Hispanic communities, a higher use of inhaled corticosteroids might be seen as appropriate. Either way, our findings are inconsistent with related studies concluding that racial minority pediatric patients with asthma were less likely to receive inhaled corticosteroids.[26, 27, 28, 29] Similarly, NHB children were most likely to receive albuterol during the preadmission visit on multivariable analysis. Although a trial dose of albuterol may be common practice in treating severe bronchiolitis, AAP recommendations do not support its routine application. Increased albuterol during preadmission may have been related to an elevated bronchiolitis severity at presentation among NHB children (as indicated by the RDSS). Potential reasons for these 2 differences in treatment remain unclear. They may represent medical management efforts by discharging physicians to prescribe: (1) corticosteroids to racial/ethnic communities with a higher risk of childhood asthma; (2) albuterol to children presenting with a more severe case of bronchiolitis. These possibilities merit further study.

The AAP also recommends diagnosis of bronchiolitis on the basis of history and physical examination; laboratory and radiologic studies should not be routinely used for diagnostic purposes. Although it is possible for chest radiograph abnormalities to be consistent with bronchiolitis, there is little evidence that an abnormal finding is associated with disease severity.[30] The clinical value of diagnostic testing in children with bronchiolitis is not well supported by evidence, and limiting exposure to radiation should be a priority.[31, 32] Our analysis found that NHW and Hispanic children were more likely to receive chest x‐rays while hospitalized when compared with NHB children. Unnecessary and increased radiation exposure in children is potentially harmful and warrants intervention to minimize risk.

Establishing systematic clinical pathways in bronchiolitis management may address the practice variation found nationwide and across race/ethnicity in this study. Although clinical guidelines provide general recommendations, clinical pathways are defined treatment protocols aiming to standardize and optimize patient outcomes and clinical efficiency. The incorporation of clinical pathways into healthcare systems has increased recently as a result of their favorable association with medical complications, healthcare costs, and LOS.[33] With respect to bronchiolitis, implementation of clinical pathways has proven to reduce use of inappropriate therapies, decrease risk of bronchiolitis‐related hospital readmission, and help with discharge planning.[30, 34, 35]

Notwithstanding the differences found in this study, management of children with bronchiolitis was, in many respects, comparable across racial/ethnic groups. For example, our multivariable analysis found no significant differences across racial/ethnic groups with respect to chest x‐rays and corticosteroid use during the preadmission visit, administration of albuterol or corticosteroids during hospitalization, use of CPAP/emntubation, ICU admission, hospital LOS, or likelihood of a bronchiolitis‐related relapse. The general lack of race/ethnic differences is consistent with similar research on inpatient management of acute asthma.[36]

This study has potential limitations. The hospitals participating in the study are predominantly urban, academically affiliated hospitals. This may result in findings that are less generalizable to rural and community hospitals. Second, the race/ethnicity classification used does not take into consideration the diversity and complexity of defining race/ethnicity in the United States. Third, bronchiolitis is defined as a clinical diagnosis that can encapsulate multiple lower respiratory infection diagnoses. As a result, there may have been variability in clinical and institutional practice. An additional limitation was utilizing RDSS to assess bronchiolitis severity. Although there is currently no validated, universally accepted score to assess bronchiolitis severity, several scores are available in the literature with varying performance. Last, the ZIP code‐based median household incomes used to assess SES are higher than federal data in similar geographic locations, potentially resulting in findings that are less generalizable.

CONCLUSION

This multicenter prospective cohort study found several differences in bronchiolitis presentation and management among children stratified by race/ethnicity in 16 geographically dispersed sites after controlling for multiple factors including SES. Our analysis showed that, when compared to NHW children, NHB children were more likely to be given albuterol during the preadmission visit and less likely to receive chest x‐rays as inpatients; Hispanic children were more likely to be discharged on inhaled corticosteroids. These differences are concerning for 2 reasons: (1) based on current evidence, race/ethnicity should not affect care in children with severe bronchiolitis; and (2) the observed differences in diagnostic testing and treatment are not recommended by the evidence‐based AAP guidelines. It is also important to note that these differences do not demonstrate that a specific race/ethnicity received better or worse clinical care. The goal of this analysis was not to determine the effectiveness of certain management tendencies in children with severe bronchiolitis, but rather to examine differences in the presentation and management of children from different racial/ethnic groups. The causes for the observed findings require further study. In the meantime, we suggest increasing the number of hospitals that incorporate clinical care pathways for severe bronchiolitis to control variation in practice and limit the impact that race/ethnicity may have in the provision of services.

Bronchiolitis is the leading cause of hospitalization for infants in the United States, costs more than $500 million annually, and has seen a 30% increase ($1.34 billion to $1.73 billion) in related hospital charges from 2000 to 2009.¹³ Almost all children <2 years old are infected with respiratory syncytial virus, the most common cause of bronchiolitis, with 40% developing clinically recognizable bronchiolitis and 2% becoming hospitalized with severe bronchiolitis.[4, 5] Current American Academy of Pediatrics (AAP) guidelines state that routine use of bronchodilators, corticosteroids, and chest x‐rays is not recommended, and supportive care is strongly encouraged.[6] However, a lack of consensus among clinicians persists regarding bronchiolitis management.[7, 8, 9, 10] Although minority children and those with a lower socioeconomic status (SES) in the United States are more likely to present with bronchiolitis to the emergency department (ED) and be subsequently admitted when compared to the general population,[11, 12, 13] to our knowledge, no study has yet examined if race/ethnicity is independently associated with differences in the presentation and management of severe bronchiolitis (ie, bronchiolitis causing hospitalization). Although a prior bronchiolitis‐related study reported that Hispanic children had a longer ED length of stay (LOS) than non‐Hispanic white (NHW) and non‐Hispanic black (NHB) children,[14] other studies concluded that race/ethnicity were not predictors of intensive care unit (ICU) admission or unscheduled healthcare visits post‐ED discharge.[15, 16]

Determining if race/ethnicity is independently associated with certain bronchiolitis management tendencies has implications from both a health disparities standpoint (ie, unequal care based on race/ethnicity) and from a clinical perspective (ie, the potential of certain practices, such as clinical pathways, to increase the likelihood of equitable treatment). To address this knowledge gap, we examined prospective data from a multicenter study designed to evaluate multiple factors related to bronchiolitis hospitalization.

METHODS

RESULTS

Of the 2130 subjects included in this analysis, 818 (38%) were NHW, 511 (24%) were NHB, and 801 (38%) were Hispanic. The median age for children was 4.0 months (IQR, 1.88.5 months), and 60% were male. Most children were publicly insured (65%), 31% had private insurance, and approximately 4% had no insurance. The median household income defined by patient ZIP code was $51,810 (IQR, $39,916$66,272), and nearly all children (97%) had a primary care provider (PCP). Approximately 21% of all children had relevant comorbidities and 17% of children were enrolled from the ICU. Overall, the median LOS was 2 days (IQR, 14 days).

The unadjusted associations between race/ethnicity and other demographic and historical characteristics are shown in Table 1. NHB and Hispanic children were more likely to have public insurance and less likely to have relevant major comorbidities when compared to NHW children. With regard to care received the week before hospitalization, NHW children were more likely to have visited their PCP, taken corticosteroids and/or antibiotics, and were least likely to have visited an ED when compared to NHB and Hispanic children.

The unadjusted associations between race/ethnicity and clinical characteristics at preadmission visit and hospital admission are shown in Table 2. RDSS values were calculated for 2130 children; 1,752 (82%) RDSS values contained all 4 components. Of those requiring imputed values, 234 (11%) were missing 1 component, and 139 (7%) were missing more than 1 component. Per RDSS scores, NHB children presented with a more severe case of bronchiolitis when compared to NHW and Hispanic children. During admission, minority children were more likely to receive nebulized albuterol and less likely to visit the ICU. NHB children received the least inpatient laboratory testing and were least likely to receive chest x‐rays during hospital admission among all groups.

Discharge treatment and outcomes at 1‐week follow‐up are shown in Table 3. A total of 1771 patients (83%) were reached by telephone. No statistically significant differences between racial/ethnic groups were found regarding hospital discharge on corticosteroids and likelihood of bronchiolitis‐related relapse.

Given the large potential for confounding regarding our initial findings, we examined multivariable‐adjusted associations of race/ethnicity and bronchiolitis management (Table 4). Receiving albuterol during the preadmission visit and chest x‐rays during hospitalization remained significantly associated with race/ethnicity in adjusted analyses, as NHB children were most likely to receive albuterol during the preadmission visit but least likely to receive chest x‐rays during hospitalization. Several outcomes with statistically significant differences found during unadjusted analyses (eg, chest x‐rays at preadmission visit, albuterol during hospitalization, CPAP/emntubation use, ICU admission, and LOS) were not independently associated with race/ethnicity in multivariable models. By contrast, adjusted analyses revealed Hispanic children as significantly more likely to be discharged on inhaled corticosteroids when compared to NHW and NHB children; this association had borderline statistical significance (P=0.08) in the unadjusted analysis. Last, we observed no significant racial/ethnic differences with respect to corticosteroids given at preadmission visit or hospitalization as well as no differences regarding bronchiolitis‐related relapse in either unadjusted or adjusted analyses.

DISCUSSION

It is unclear if management and treatment differences found in children with severe bronchiolitis are associated with race/ethnicity. We sought to determine if such differences exist by analyzing data from a prospective multicenter cohort study. Differences in management and treatment are discussed in the context of AAP guidelines, as they are widely used in clinical practice.

The RDSS was used to help assess severity of illness across race/ethnicity. NHB children had the highest RDSS score (ie, most severe bronchiolitis presentation) compared to NHW and Hispanic children. The reason for this difference in severity is unclear, but a potential explanation may be that minority communities lack access to care and as a result delay care and treatment for respiratory disease until care seems absolutely necessary.[19] Indeed, in our sample, minority children were less likely to visit their PCP and take corticosteroids the week before hospitalization when compared with NHW children. Our finding runs counter to a similar study by Boudreaux et al. that found no association between race/ethnicity and the clinical presentation of children with acute asthma during the preadmission setting.[20] The more severe bronchiolitis presentation among NHB children may have suggested that these children would require a longer hospital LOS (3 days). However, our multivariable analysis found no difference in LOS across racial/ethnic groups. This LOS finding is intriguing given previous studies suggesting that minorities, of diverse ages and with diverse diagnoses, were more likely to have a shorter LOS (as well as less likely to be admitted to the ICU with a similar diagnosis) when compared to nonminorities.[21, 22] Additionally, because our study sampled 16 sites, variation in clinical judgment and pediatric ICU protocol may have also played a role.[23]

Our findings also shed light on how differences in bronchiolitis management relate to AAP guidelines. According to the AAP, corticosteroid medications should not be used routinely in the management of bronchiolitis. Despite this recommendation, previous reports indicate that up to 60% of infants with severe bronchiolitis receive corticosteroid therapy.[24, 25] Our finding that Hispanic children with severe bronchiolitis were most likely to be discharged on inhaled corticosteroids is potentially concerning, as it exposes a subset of children to treatment that is not recommended. On the other hand, given the increased risk of future asthma in Hispanic communities, a higher use of inhaled corticosteroids might be seen as appropriate. Either way, our findings are inconsistent with related studies concluding that racial minority pediatric patients with asthma were less likely to receive inhaled corticosteroids.[26, 27, 28, 29] Similarly, NHB children were most likely to receive albuterol during the preadmission visit on multivariable analysis. Although a trial dose of albuterol may be common practice in treating severe bronchiolitis, AAP recommendations do not support its routine application. Increased albuterol during preadmission may have been related to an elevated bronchiolitis severity at presentation among NHB children (as indicated by the RDSS). Potential reasons for these 2 differences in treatment remain unclear. They may represent medical management efforts by discharging physicians to prescribe: (1) corticosteroids to racial/ethnic communities with a higher risk of childhood asthma; (2) albuterol to children presenting with a more severe case of bronchiolitis. These possibilities merit further study.

The AAP also recommends diagnosis of bronchiolitis on the basis of history and physical examination; laboratory and radiologic studies should not be routinely used for diagnostic purposes. Although it is possible for chest radiograph abnormalities to be consistent with bronchiolitis, there is little evidence that an abnormal finding is associated with disease severity.[30] The clinical value of diagnostic testing in children with bronchiolitis is not well supported by evidence, and limiting exposure to radiation should be a priority.[31, 32] Our analysis found that NHW and Hispanic children were more likely to receive chest x‐rays while hospitalized when compared with NHB children. Unnecessary and increased radiation exposure in children is potentially harmful and warrants intervention to minimize risk.

Establishing systematic clinical pathways in bronchiolitis management may address the practice variation found nationwide and across race/ethnicity in this study. Although clinical guidelines provide general recommendations, clinical pathways are defined treatment protocols aiming to standardize and optimize patient outcomes and clinical efficiency. The incorporation of clinical pathways into healthcare systems has increased recently as a result of their favorable association with medical complications, healthcare costs, and LOS.[33] With respect to bronchiolitis, implementation of clinical pathways has proven to reduce use of inappropriate therapies, decrease risk of bronchiolitis‐related hospital readmission, and help with discharge planning.[30, 34, 35]

Notwithstanding the differences found in this study, management of children with bronchiolitis was, in many respects, comparable across racial/ethnic groups. For example, our multivariable analysis found no significant differences across racial/ethnic groups with respect to chest x‐rays and corticosteroid use during the preadmission visit, administration of albuterol or corticosteroids during hospitalization, use of CPAP/emntubation, ICU admission, hospital LOS, or likelihood of a bronchiolitis‐related relapse. The general lack of race/ethnic differences is consistent with similar research on inpatient management of acute asthma.[36]

This study has potential limitations. The hospitals participating in the study are predominantly urban, academically affiliated hospitals. This may result in findings that are less generalizable to rural and community hospitals. Second, the race/ethnicity classification used does not take into consideration the diversity and complexity of defining race/ethnicity in the United States. Third, bronchiolitis is defined as a clinical diagnosis that can encapsulate multiple lower respiratory infection diagnoses. As a result, there may have been variability in clinical and institutional practice. An additional limitation was utilizing RDSS to assess bronchiolitis severity. Although there is currently no validated, universally accepted score to assess bronchiolitis severity, several scores are available in the literature with varying performance. Last, the ZIP code‐based median household incomes used to assess SES are higher than federal data in similar geographic locations, potentially resulting in findings that are less generalizable.

CONCLUSION

This multicenter prospective cohort study found several differences in bronchiolitis presentation and management among children stratified by race/ethnicity in 16 geographically dispersed sites after controlling for multiple factors including SES. Our analysis showed that, when compared to NHW children, NHB children were more likely to be given albuterol during the preadmission visit and less likely to receive chest x‐rays as inpatients; Hispanic children were more likely to be discharged on inhaled corticosteroids. These differences are concerning for 2 reasons: (1) based on current evidence, race/ethnicity should not affect care in children with severe bronchiolitis; and (2) the observed differences in diagnostic testing and treatment are not recommended by the evidence‐based AAP guidelines. It is also important to note that these differences do not demonstrate that a specific race/ethnicity received better or worse clinical care. The goal of this analysis was not to determine the effectiveness of certain management tendencies in children with severe bronchiolitis, but rather to examine differences in the presentation and management of children from different racial/ethnic groups. The causes for the observed findings require further study. In the meantime, we suggest increasing the number of hospitals that incorporate clinical care pathways for severe bronchiolitis to control variation in practice and limit the impact that race/ethnicity may have in the provision of services.

Bronchiolitis is the leading cause of hospitalization for infants in the United States, costs more than $500 million annually, and has seen a 30% increase ($1.34 billion to $1.73 billion) in related hospital charges from 2000 to 2009.¹³ Almost all children <2 years old are infected with respiratory syncytial virus, the most common cause of bronchiolitis, with 40% developing clinically recognizable bronchiolitis and 2% becoming hospitalized with severe bronchiolitis.[4, 5] Current American Academy of Pediatrics (AAP) guidelines state that routine use of bronchodilators, corticosteroids, and chest x‐rays is not recommended, and supportive care is strongly encouraged.[6] However, a lack of consensus among clinicians persists regarding bronchiolitis management.[7, 8, 9, 10] Although minority children and those with a lower socioeconomic status (SES) in the United States are more likely to present with bronchiolitis to the emergency department (ED) and be subsequently admitted when compared to the general population,[11, 12, 13] to our knowledge, no study has yet examined if race/ethnicity is independently associated with differences in the presentation and management of severe bronchiolitis (ie, bronchiolitis causing hospitalization). Although a prior bronchiolitis‐related study reported that Hispanic children had a longer ED length of stay (LOS) than non‐Hispanic white (NHW) and non‐Hispanic black (NHB) children,[14] other studies concluded that race/ethnicity were not predictors of intensive care unit (ICU) admission or unscheduled healthcare visits post‐ED discharge.[15, 16]

Determining if race/ethnicity is independently associated with certain bronchiolitis management tendencies has implications from both a health disparities standpoint (ie, unequal care based on race/ethnicity) and from a clinical perspective (ie, the potential of certain practices, such as clinical pathways, to increase the likelihood of equitable treatment). To address this knowledge gap, we examined prospective data from a multicenter study designed to evaluate multiple factors related to bronchiolitis hospitalization.

METHODS

RESULTS

Of the 2130 subjects included in this analysis, 818 (38%) were NHW, 511 (24%) were NHB, and 801 (38%) were Hispanic. The median age for children was 4.0 months (IQR, 1.88.5 months), and 60% were male. Most children were publicly insured (65%), 31% had private insurance, and approximately 4% had no insurance. The median household income defined by patient ZIP code was $51,810 (IQR, $39,916$66,272), and nearly all children (97%) had a primary care provider (PCP). Approximately 21% of all children had relevant comorbidities and 17% of children were enrolled from the ICU. Overall, the median LOS was 2 days (IQR, 14 days).

The unadjusted associations between race/ethnicity and other demographic and historical characteristics are shown in Table 1. NHB and Hispanic children were more likely to have public insurance and less likely to have relevant major comorbidities when compared to NHW children. With regard to care received the week before hospitalization, NHW children were more likely to have visited their PCP, taken corticosteroids and/or antibiotics, and were least likely to have visited an ED when compared to NHB and Hispanic children.

The unadjusted associations between race/ethnicity and clinical characteristics at preadmission visit and hospital admission are shown in Table 2. RDSS values were calculated for 2130 children; 1,752 (82%) RDSS values contained all 4 components. Of those requiring imputed values, 234 (11%) were missing 1 component, and 139 (7%) were missing more than 1 component. Per RDSS scores, NHB children presented with a more severe case of bronchiolitis when compared to NHW and Hispanic children. During admission, minority children were more likely to receive nebulized albuterol and less likely to visit the ICU. NHB children received the least inpatient laboratory testing and were least likely to receive chest x‐rays during hospital admission among all groups.

Discharge treatment and outcomes at 1‐week follow‐up are shown in Table 3. A total of 1771 patients (83%) were reached by telephone. No statistically significant differences between racial/ethnic groups were found regarding hospital discharge on corticosteroids and likelihood of bronchiolitis‐related relapse.

Given the large potential for confounding regarding our initial findings, we examined multivariable‐adjusted associations of race/ethnicity and bronchiolitis management (Table 4). Receiving albuterol during the preadmission visit and chest x‐rays during hospitalization remained significantly associated with race/ethnicity in adjusted analyses, as NHB children were most likely to receive albuterol during the preadmission visit but least likely to receive chest x‐rays during hospitalization. Several outcomes with statistically significant differences found during unadjusted analyses (eg, chest x‐rays at preadmission visit, albuterol during hospitalization, CPAP/emntubation use, ICU admission, and LOS) were not independently associated with race/ethnicity in multivariable models. By contrast, adjusted analyses revealed Hispanic children as significantly more likely to be discharged on inhaled corticosteroids when compared to NHW and NHB children; this association had borderline statistical significance (P=0.08) in the unadjusted analysis. Last, we observed no significant racial/ethnic differences with respect to corticosteroids given at preadmission visit or hospitalization as well as no differences regarding bronchiolitis‐related relapse in either unadjusted or adjusted analyses.

DISCUSSION

It is unclear if management and treatment differences found in children with severe bronchiolitis are associated with race/ethnicity. We sought to determine if such differences exist by analyzing data from a prospective multicenter cohort study. Differences in management and treatment are discussed in the context of AAP guidelines, as they are widely used in clinical practice.

The RDSS was used to help assess severity of illness across race/ethnicity. NHB children had the highest RDSS score (ie, most severe bronchiolitis presentation) compared to NHW and Hispanic children. The reason for this difference in severity is unclear, but a potential explanation may be that minority communities lack access to care and as a result delay care and treatment for respiratory disease until care seems absolutely necessary.[19] Indeed, in our sample, minority children were less likely to visit their PCP and take corticosteroids the week before hospitalization when compared with NHW children. Our finding runs counter to a similar study by Boudreaux et al. that found no association between race/ethnicity and the clinical presentation of children with acute asthma during the preadmission setting.[20] The more severe bronchiolitis presentation among NHB children may have suggested that these children would require a longer hospital LOS (3 days). However, our multivariable analysis found no difference in LOS across racial/ethnic groups. This LOS finding is intriguing given previous studies suggesting that minorities, of diverse ages and with diverse diagnoses, were more likely to have a shorter LOS (as well as less likely to be admitted to the ICU with a similar diagnosis) when compared to nonminorities.[21, 22] Additionally, because our study sampled 16 sites, variation in clinical judgment and pediatric ICU protocol may have also played a role.[23]

Our findings also shed light on how differences in bronchiolitis management relate to AAP guidelines. According to the AAP, corticosteroid medications should not be used routinely in the management of bronchiolitis. Despite this recommendation, previous reports indicate that up to 60% of infants with severe bronchiolitis receive corticosteroid therapy.[24, 25] Our finding that Hispanic children with severe bronchiolitis were most likely to be discharged on inhaled corticosteroids is potentially concerning, as it exposes a subset of children to treatment that is not recommended. On the other hand, given the increased risk of future asthma in Hispanic communities, a higher use of inhaled corticosteroids might be seen as appropriate. Either way, our findings are inconsistent with related studies concluding that racial minority pediatric patients with asthma were less likely to receive inhaled corticosteroids.[26, 27, 28, 29] Similarly, NHB children were most likely to receive albuterol during the preadmission visit on multivariable analysis. Although a trial dose of albuterol may be common practice in treating severe bronchiolitis, AAP recommendations do not support its routine application. Increased albuterol during preadmission may have been related to an elevated bronchiolitis severity at presentation among NHB children (as indicated by the RDSS). Potential reasons for these 2 differences in treatment remain unclear. They may represent medical management efforts by discharging physicians to prescribe: (1) corticosteroids to racial/ethnic communities with a higher risk of childhood asthma; (2) albuterol to children presenting with a more severe case of bronchiolitis. These possibilities merit further study.

The AAP also recommends diagnosis of bronchiolitis on the basis of history and physical examination; laboratory and radiologic studies should not be routinely used for diagnostic purposes. Although it is possible for chest radiograph abnormalities to be consistent with bronchiolitis, there is little evidence that an abnormal finding is associated with disease severity.[30] The clinical value of diagnostic testing in children with bronchiolitis is not well supported by evidence, and limiting exposure to radiation should be a priority.[31, 32] Our analysis found that NHW and Hispanic children were more likely to receive chest x‐rays while hospitalized when compared with NHB children. Unnecessary and increased radiation exposure in children is potentially harmful and warrants intervention to minimize risk.

Establishing systematic clinical pathways in bronchiolitis management may address the practice variation found nationwide and across race/ethnicity in this study. Although clinical guidelines provide general recommendations, clinical pathways are defined treatment protocols aiming to standardize and optimize patient outcomes and clinical efficiency. The incorporation of clinical pathways into healthcare systems has increased recently as a result of their favorable association with medical complications, healthcare costs, and LOS.[33] With respect to bronchiolitis, implementation of clinical pathways has proven to reduce use of inappropriate therapies, decrease risk of bronchiolitis‐related hospital readmission, and help with discharge planning.[30, 34, 35]

Notwithstanding the differences found in this study, management of children with bronchiolitis was, in many respects, comparable across racial/ethnic groups. For example, our multivariable analysis found no significant differences across racial/ethnic groups with respect to chest x‐rays and corticosteroid use during the preadmission visit, administration of albuterol or corticosteroids during hospitalization, use of CPAP/emntubation, ICU admission, hospital LOS, or likelihood of a bronchiolitis‐related relapse. The general lack of race/ethnic differences is consistent with similar research on inpatient management of acute asthma.[36]

This study has potential limitations. The hospitals participating in the study are predominantly urban, academically affiliated hospitals. This may result in findings that are less generalizable to rural and community hospitals. Second, the race/ethnicity classification used does not take into consideration the diversity and complexity of defining race/ethnicity in the United States. Third, bronchiolitis is defined as a clinical diagnosis that can encapsulate multiple lower respiratory infection diagnoses. As a result, there may have been variability in clinical and institutional practice. An additional limitation was utilizing RDSS to assess bronchiolitis severity. Although there is currently no validated, universally accepted score to assess bronchiolitis severity, several scores are available in the literature with varying performance. Last, the ZIP code‐based median household incomes used to assess SES are higher than federal data in similar geographic locations, potentially resulting in findings that are less generalizable.

CONCLUSION

This multicenter prospective cohort study found several differences in bronchiolitis presentation and management among children stratified by race/ethnicity in 16 geographically dispersed sites after controlling for multiple factors including SES. Our analysis showed that, when compared to NHW children, NHB children were more likely to be given albuterol during the preadmission visit and less likely to receive chest x‐rays as inpatients; Hispanic children were more likely to be discharged on inhaled corticosteroids. These differences are concerning for 2 reasons: (1) based on current evidence, race/ethnicity should not affect care in children with severe bronchiolitis; and (2) the observed differences in diagnostic testing and treatment are not recommended by the evidence‐based AAP guidelines. It is also important to note that these differences do not demonstrate that a specific race/ethnicity received better or worse clinical care. The goal of this analysis was not to determine the effectiveness of certain management tendencies in children with severe bronchiolitis, but rather to examine differences in the presentation and management of children from different racial/ethnic groups. The causes for the observed findings require further study. In the meantime, we suggest increasing the number of hospitals that incorporate clinical care pathways for severe bronchiolitis to control variation in practice and limit the impact that race/ethnicity may have in the provision of services.

Peripherally inserted central venous catheters (PICCs) are used for a variety of indications, including administration of long‐term intravenous (IV) antibiotics, home IV medications, chemotherapy, and parenteral nutrition.[1, 2, 3] Additionally, PICCs have also been recognized as an alternative to large‐bore central venous catheters such as subclavian or internal jugular central venous catheters. PICCs have been associated with fewer bloodstream infections in patients with cancer than tunneled catheters.[4] Compared to central venous catheters, they demonstrate reduced complication rates,[5] decreased cost,[6] and increased safety for longer durations of use.[1, 2, 3, 7, 8, 9]

Despite the numerous benefits of PICCs, Prandoni et al. estimate an all‐cause complication rate of 12% to 17% with the use of PICCs.[10] Associated complications include infection,[11] pain, bleeding, and mechanical dysfunction, all of which contribute to patient discomfort and additional healthcare costs.[12] Bloodstream infections, for example, had previously been thought to occur at a substantially lower rate in PICCs than central venous catheters.[13] However, a recent systematic review suggests the rate of PICC‐associated bloodstream infections in the inpatient setting is actually comparable to that of central venous catheters.[14] Perhaps the most serious PICC‐associated complication is catheter‐related venous thrombosis. A recent systematic review and meta‐analysis found evidence to suggest the rate of catheter‐related venous thrombosis was highest in patients with cancer or critical illness¹⁵; additionally, rates of thrombosis associated with PICCs were higher than those associated with subclavian or internal jugular central venous catheters.[15, 16] Fletcher et al. showed an 8.1% incidence of symptomatic PICC‐related upper extremity deep vein thrombosis (DVT) in the neurosurgical intensive care unit, with 15% of patients subsequently developing a pulmonary embolism.[17] A recent prospective, randomized controlled trial by Itkin et al. similarly demonstrated symptomatic DVT rates of approximately 4%.[18] However, in this study, when PICCs were routinely screened for thrombosis (with or without associated symptoms), approximately 72% demonstrated thrombosis,[18] suggesting that many PICC‐associated thromboses may be clinically undetected. This may have far‐reaching clinical significance, as pulmonary embolism complicates upper extremity DVT in 9% of cases and can result in a mortality rate as high as 25%.[10, 19]

Some strategies to reduce the rate of catheter‐related complications include identification of characteristics that put patients at risk. Many potential risk factors have been investigated, including catheter size,[12, 20, 21, 22, 23, 24] choice of vein,[24] location of catheter tip,[25] and history of malignancy or prior DVT.[12] However, to date, no definitive consensus has been reached. Special attention has been paid to the investigation of underlying risk factors and treatment for catheter‐related DVT, given its significant morbidity and mortality. Results have been equivocal, though, and in some instances, complicated by a diagnosis of underlying malignancy.[26, 27, 28]

As PICCs become more widely utilized, assessments of factors that place patients at greater risk of PICC‐related complications are needed.[21] The purpose of this study was to establish the incidence of complications associated with PICCs placed in the inpatient setting and examine risk factors predisposing patients to these complications.

MATERIALS AND METHODS

RESULTS

In 2009, 1444 PICCs were placed, and 170 cases in which patients experienced complications associated with PICC placement were identified, resulting in a complication rate of 11.77% (95% CI: 10.11%‐13.44%). The most common complications experienced by our patient population included catheter‐associated thrombosis (3%, n = 46), mechanical complications (4%, n=67), inadvertent catheter dislodgement (2%, n=36), mechanical dysfunction (2%, n=30), retained portion of the catheter following catheter removal (<1%, n=1), catheter‐associated bloodstream infections (2%, n=24), and cellulitis at the catheter insertion site (1%, n=15). Other documented complications included unexplained fever and bleeding (Table 1).

The mean age of the total cohort (N=340), comprised of case (N=170) and control (N=170) groups, was 58 years (SD 17), and 55% (n=94) were females. There were no significant differences in complications between groups based on ethnicity (P=0.66). In the case group, 46% (n=78) of PICCs were placed by the radiology team, 41% (n=69) were placed by the internal medicine team, and 14% (n=23) were placed by nursing. In the control group, 44% (n=74) of PICCs were placed by radiology, 36% (n=62) by internal medicine, and 20% (n=34) by nursing. Based on univariate conditional analysis, provider team was not significantly associated with complications (P=0.29).

DISCUSSION

The goal of this study was to identify factors related to PICC placement that place the general population of patients at risk. The type and rate of complications associated with PICCs in this study were similar to those previously reported in the literature including catheter‐related infection and thrombosis.[10, 32] Two unique risk factors, not well recognized previously,[10, 27, 28, 33] were observed in this study: malnutrition and after‐hours placement. Malnutrition, defined as serum albumin <3 g/dL was associated with an increase in PICC‐related complications (such as catheter‐associated bloodstream infections and cellulitis) and catheter‐related thrombosis. Malnutrition itself has long been associated with a decreased resistance to infection[34]; in addition, low serum albumin may also be a marker of the presence of other severe comorbidities, which may contribute to increased risk of thrombosis. It has been noted in previous studies that critical illness increases risk of thrombosis.[15] Despite an exhaustive search of the literature, we have been unable to find additional studies examining the extent to which malnutrition may impact PICC‐associated complications.

After‐hours placement was also associated with increased nonmechanical complications, as well as catheter‐related thrombosis. In an effort to improve both patient and consulting provider satisfaction and provide more expedient service, PICCs were often placed after hours (between 5 _pm and 8 _am) by both interventional radiology (n=14) and internal medicine (n=15) teams.

LOS has been associated with PICC placement complications in other studies.[12] In both primary and secondary analyses, hospital stays >30 days were associated with a higher risk of complications than hospitalizations <7 days. In light of the clinical significance of catheter‐related thrombosis, a subgroup analysis of patients with an LOS >30 days was conducted. The conditional univariate regression analysis showed an increased risk with greater LOS, malnutrition, and after‐hours placement. Use of anticoagulant or antiplatelet agents were associated with decreased risk of thrombosis (Table 4). The association between LOS and PICC‐related thrombosis is consistent with findings from Evans et al. involving 1728 patients in a similar center.[12] In these circumstances, increased LOS may be a surrogate marker for increased severity of illness, in that those patients who are more ill require lengthier hospitalizations. In a systematic review and meta‐analysis, Chopra et al. observed that increased severity of illness correlated with higher rates of catheter‐associated thrombosis, which is supportive of these findings.[15]

In the multivariate logistic regression analysis, BMI >30 was associated with a statistically significant increased risk for PICC‐associated complications after adjusting for anticoagulation and time of placement (Table 2). In the secondary analysis, where patients with mechanical complications were removed, BMI >30 was no longer associated with an increased risk for PICC‐associated complications (Table 3). This suggests that patients with a BMI >30 had an increased risk of mechanical complications, but were not necessarily at increased risk of developing other complications, such as catheter‐related thrombosis, infection, or bleeding. This finding is congruent with studies by Evans et al.,[12] who found no association between BMI and catheter‐associated thrombosis. Our association between BMI and complications is unique; to date, there are few additional studies that examine the extent to which BMI impacts the rate and type of complications associated with PICCs. At this time, the mechanism of the association between mechanical complications (such as inadvertent catheter removal or mechanical malfunction) and BMI is uncertain and warrants further investigation.

CONCLUSIONS AND FUTURE DIRECTIONS

Our results suggest that more stringent screening of patients undergoing PICC placement may reduce the risk of complications, with special attention to characteristics such as BMI >30, increased LOS, and protein‐calorie malnutrition (albumin <3). Furthermore, placement of PICC lines in emergent or after‐hours settings should be carefully considered and weighed against relative risks of central venous catheter placement. Further examination of the role anticoagulant and antiplatelet agents may have in the prevention of catheter‐related thrombosis should be undertaken. We hope that the identification of these risk factors will decrease the rate of complications and ultimately enhance patient safety and satisfaction.