Jonathan Santiago, MPH

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.