33 - Diagnostic Variation in Children 12-23 Months with Acute Viral Lower Respiratory Illness

Friday, April 28, 2023

5:15 PM – 7:15 PM ET

Poster Number: 33
Publication Number: 33.111

Patrick S. Walsh, Medical College of Wisconsin, Milwaukee, WI, United States; Wendi-Jo Wendt, Medical College of Wisconsin, Mequon, WI, United States; Matthew J. Lipshaw, CINCINNATI CHILDREN'S HOSPITAL MEDICAL CENTER, Cincinnati, OH, United States

Presenting Author(s)

Patrick S. Walsh, MD, MS (he/him/his)

Assistant Professor
Medical College of Wisconsin
Milwaukee, Wisconsin, United States

Background: There is considerable overlap between the clinical entities of asthma and bronchiolitis; and it is difficult to distinguish the two except by age. US and European guidelines for bronchiolitis include children up to 23 months of age, while other regional bronchiolitis guidelines only apply to infants < 12 months. While most studies of guideline adherence only examine children with the diagnosis of bronchiolitis, we hypothesize that there may be considerable variability in diagnostic coding of bronchiolitis and asthma in acutely wheezing children aged 12-23 months, which may severely limit assessment of bronchiolitis guideline adherence in this age group.

Objective: To describe diagnostic variation in acutely wheezing children aged 12-23 months, and to determine factors associated with a diagnosis of asthma.

Design/Methods: We conducted a retrospective observational analysis using the Pediatric Health Information System database. We included children aged 12-23 months with a discharge diagnosis for bronchiolitis, asthma, wheeze, or bronchospasm in an emergency department or hospital encounter from 2017-2021. We described variation in diagnosis patterns by hospital and evaluated factors associated with a diagnosis of asthma using univariate and multivariable mixed-effects models.

Results: We analyzed 211,136 encounters from 42 hospitals. Of included encounters, 35.2% were diagnosed with asthma, 58.5% with bronchiolitis, 12.6% with wheeze, and 3.0% with bronchospasm. Hospitals varied widely in which diagnoses were assigned, with some diagnosing up to five times more bronchiolitis than asthma, and others diagnosing nearly twice as much asthma compared to bronchiolitis. Use of only the nonspecific diagnoses of wheeze or bronchospasm also varied by institution, ranging from 1%-34% of encounters (Figure). After adjusting for clustering by hospital, we found differences in odds of asthma diagnosis based on month of age (OR 1.13 [1.12-1.13]), demographic factors, highest level of care, previous albuterol use (OR 2.29 [2.22-2.36]), and number of previous wheezing encounters (OR 1.3 [1.28-1.31]) (Table).

Conclusion(s):

Hospitals vary in assigning diagnoses of asthma, bronchiolitis, wheeze, and bronchospasm in children aged 12-23 months. Children who were older, admitted to the inpatient floor or intensive care, and who had received albuterol previously were more likely to receive a diagnosis of asthma. These findings illustrate the clinical overlap between asthma and bronchiolitis in this age group. Hospitals with lower rates of bronchiolitis diagnosis may obscure guideline non-adherence.