Elsevier

The Journal of Pediatrics

Volume 147, Issue 3, September 2005, Pages 355-361
The Journal of Pediatrics

Original Article
Regional Variation in ICU Care for Pediatric Patients with Asthma

https://doi.org/10.1016/j.jpeds.2005.05.008Get rights and content

Objective

To determine adherence to guidelines for severe asthma care and evaluate regional variability in practice among pediatric intensive care units (PICU).

Study design

A retrospective cohort study of children treated for asthma in a PICU during 2000 to 2003.

We utilized the Pediatric Health Information System (PHIS) database to identify patients and determine use of asthma therapies when patients did not improve with standard therapy (inhaled β-agonists and systemic corticosteroids).

Results

Of 7125 children studied, 59% received inhaled anticholinergic medications. Use of other therapies included systemic β-agonists (n = 1841 [26%]), magnesium sulfate (n = 1521 [21%]), methylxanthines (n = 426 [6%]), inhaled helium-oxigen gas mixture (heliox) (n = 740 [10%]), and endotracheal intubation with ventilation (n = 1024 [14%]). Use of therapies varied by census region. Over half the patients (n = 524) who received ventilation did so for ≤1 day. Adjusted for severity of illness, use of mechanical ventilation varied significantly by census division; however, much of the variation was among children ventilated for ≤1 day.

Conclusion

Adherence to national guidelines for use of inhaled anticholinergics among critically ill children is low, and marked variation in use of invasive ventilation exists. More explicit guidelines regarding indications for invasive ventilation may improve asthma care.

Section snippets

Data Source

This study utilized data from a large, multi-institutional administrative database, the Pediatric Health Information System (PHIS). The PHIS database is maintained by the pediatric hospital members of the Child Health Corporation of America (CHCA), which currently includes 41 member hospitals.8 CHCA is a business alliance of pediatric hospitals that provides a range of products and services designed to reduce cost, increase revenue, and enhance the competitiveness of children's hospitals. The

Results

Of 87,875 pediatric patients treated for asthma in a participating hospital during the study period, 7125 (8%) received care in a PICU. Selected demographic features of the PICU patients are shown in Table I. One thousand twenty-four children (14%) received invasive ventilation. Use of mechanical ventilation differed by area of the country, as did severity of illness assessed by APR-DRG (highest severity score). Use of mechanical ventilation varied from 6% in the Pacific census division

Discussion

Our study found large variability in use of asthma therapies for pediatric patients with severe exacerbations. Variability was noted in the administration of recommended medications such as inhaled anticholinergics as well as medications with less convincing evidence to support their use for severe exacerbations (eg, methylxanthines and systemic β-agonists). There was marked regional variation in the use of inhaled heliox, noninvasive mechanical ventilation, and invasive mechanical ventilation

References (39)

  • K.B. Weiss et al.

    An economic evaluation of asthma in the United States

    N Engl J Med

    (1992)
  • P. Lozano et al.

    Health care utilization and cost among children with asthma who were enrolled in a health maintenance organization

    Pediatrics

    (1997)
  • National Heart Lung Blood Institute, National Asthma Education and Prevention Program

    Practical guide for the diagnosis and management of asthma. [Based on the Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma]

    (1997)
  • Pocket Guide for Asthma Management and Prevention in Children, Global Initiative for Asthma. National Institutes of...
  • M. Lara et al.

    Improving childhood asthma outcomes in the United States: a blueprint for policy action

    Pediatrics

    (2002)
  • Pediatric Health Information System (PHIS). Child Health Corporation of America. Availabe online at...
  • St Anthony's Softbound ICD-9 Code Book, 1997

    (1996)
  • 3M™ All Patient Refined DRG (APR-DRG) Software. Available online at...
  • Description of methodologic and hospital specific factors affecting the calculation of a children's hospital DRG case...
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