Reducing Unnecessary Utilization in Acute Bronchiolitis Care

1. Reducing Unnecessary Utilization in Acute Bronchiolitis Care Shawn Ralston, MD Matthew Garber, MD Steve Narang, MD Mark Shen, MD Brian Pate, MD (for the members of the VIP Network)

2. Disclosure I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. I will discuss the off label use of medication in this presentation

4. Why Bronchiolitis? • Most common reason for hospitalization in pediatrics • Significant and widespread variation in care documented • Second most expensive diagnosis using KID database – high volume + high utilization

5. Why Bronchiolitis? • AAP practice guideline has been available since 2006 • 15 years have passed since the first meta-analyses of bronchodilator efficacy and 12 years since the first steroid meta-analysis • Strong sense that over-utilization remains common and that something else needs to be done to disseminate evidence-based guidelines

6. The Value in Inpatient Pediatrics Network Collaborative QI project which emerged out of the AAP SOHM Frustration with lack of pediatric resources for quality improvement in smaller academic and community hospitals Frustration with lack of relevant benchmarks for our most common disease The Project

7. Goal of this Project • Evaluate the real world effectiveness of peer group benchmarking to decrease unnecessary utilization in inpatient bronchiolitis care • In the absence of formal, national quality measures • Without generating new resources or data • In a diverse group of institutions, most without a research mission

8. Include any institution that cares for hospitalized children regardless of mission or resources Provide a support group for site leaders attempting to change bronchiolitis management on the local level Provide a peer group of hospitalists within which to benchmark Promote sharing of resources across practice sites VIP Overview

9. Reduce the percentage of patients receiving any: Bronchodilator (albuterol, xopenex, epinephrine, ipratropium) Steroids (inhaled or systemic) Chest radiography RSV testing Chest physiotherapy Balancing Measures – LOS, Readmissions, VDC Specific Aims – Bronchiolitis Project

10. The Intervention • A virtual community based on benchmarking • Adoption of shared group norms about appropriate bronchiolitis care • Project website • QI coaching (peer-to-peer) • Shared bibliographies, order sets, scores, parent handouts, etc. • Yearly meeting and awards

11. Timeline • 2008 – group organized and data collected for both 2007 and 2008 to serve as baseline. • 2009 - hospitals actively working on local approaches to the problem, sharing resources and responding to yearly feedback. First group meeting held. • 2010 – Most centers had achieved significant improvement over baseline.

12. Participants/Demographics • 17 centers from 15 states • 90% non-freestanding children’s facilities • 70% did not have a guideline prior to joining the network • 30% were urban (located in population center of > 1 million) • Wide range of volume (from an average of 40 to over 600 bronchiolitis admission per year) • Wide range of payor mix (from 15% to 71% Medicaid)

13. Primary Diagnosis = 466.11 or 466.19 Exclude hospitalizations with PICU charges and with a specific list of complicating illnesses Hospital billing data used for all measures No patient level information collected A total of 11,568 hospitalizations were analyzed The Data

14. Summary of Results

15. Results - Bronchodilator Utilization

16. Bronchodilators in Doses per Patient

17. CPT Utilization

18. Intra-institutional Patterns of Bronchodilator Utilization

19. VIP Network Project Sites & Leaders • Arizona: John Pope, MD, MPH; Scottsdale Healthcare Hospital System • Florida: Michele Lossius, MD, Shands Hospital for Children at University of Florida • Illinois: Trina Croland, MD, Children’s Hospital of Illinois and University of Illinois • Kentucky: Jeff Bennett, MD, Kentucky Children’s Hospital and University of Kentucky College of Medicine • Louisiana: Steve Narang, MD, Our Lady of the Lake Regional Medical Center • Maine: Jennifer Jewell, MD, Barbara Bush Children’s Hospital • Maryland: Scott Krugman, MD, Franklin Square Hospital Center; Elizabeth Robbins, MD, Anne Arundel Medical Center • New York: Joanne Nazif, MD and Sheila Liewehr, MD, Children’s Hospital at Montefiore • North Carolina:Ansley Miller, MD, Mission Hospital • Ohio: Michelle Marks, DO and Rita Pappas, MD, Cleveland Clinic • South Carolina: Matthew Garber, MD, Palmetto Health Children’s Hospital • Tennesee: Jeanann Pardue, MD, East Tennessee Children’s Hospital • Texas: Ricardo Quinonez, MD, Texas Children’s Hospital; Shawn Ralston, MD, Christus Santa Rosa Children’s Hospital • Virginia: Bryan R. Fine, MD, MPH, Children’s Hospital of The King’s Daughters; Michael Ryan, MD, Children’s Hospital of Richmond