215 Confirmation of Racial/Ethnic Disparities in the Management of Severe Bronchiolitis

Abstract

Bronchiolitis is the #1 cause of hospitalization among infants in the U.S. and is associated with an increased risk of asthma. In an earlier multicenter study (Santiago et al. J Hosp Med 2014; 9: 565-572), we reported three racial/ethnic differences in the management of severe bronchiolitis: 1) ED/clinic albuterol use, 2) inpatient diagnostic imaging, and 3) prescription of inhaled corticosteroids at discharge. In the current study, we examine if racial/ethnic differences persist in a new multicenter severe bronchiolitis cohort. We enrolled infants (age <1y) with severe bronchiolitis between 2011 and 2014 at 17 teaching hospitals across 13 states in the 35th Multicenter Airway Research Collaboration (MARC-35) study. In total, 1016 infants had a structured interview and chart review during their bronchiolitis hospitalization. Race/ethnicity was assigned based on the guardian’s response to U.S. Census questions: Hispanic (y/n) and Race (eg, white, black, Asian - mark all that apply). Infants were categorized into three groups: non-Hispanic white (NHW), non-Hispanic black (NHB), or Hispanic. For analytical reasons, we excluded 39 infants who could not be categorized into these groups. This resulted in a total of 977 (96%) infants in our analytical dataset. Multivariable logistic regression was used to examine the independent association between race/ethnicity and diagnostic imaging, ED/clinic and inpatient treatment (albuterol, corticosteroids), management (intensive care interventions and length-of-stay), discharge on corticosteroids, and bronchiolitis relapse within three weeks. Among 977 infants, 430 (44%) were NHW, 239 (24%) were NHB, and 308 (32%) were Hispanic. The median age at enrollment was 3.2 months; 60% were male and 60% had public health insurance. Most infants tested positive for RSV (81%) and did not have a breathing problem before enrollment (80%); the median hospital length-of-stay was 2 days. In multivariable analyses, with NHW infants as reference group, we focused on three previously reported differences (Figure). We did not confirm the previously reported difference for ED/clinic albuterol across the three groups. We did confirm the other two findings, with NHB infants less likely to receive chest x-rays during hospitalization (OR: 0.64; 95% CI: 0.45-0.93), and Hispanic infants more likely to be discharged on corticosteroids (OR: 1.91; 95% CI: 1.05-3.48). We again found no significant racial/ethnic differences for all other outcomes: inpatient corticosteroid use, hospital length of stay, intensive care interventions, or worsening of bronchiolitis requiring medical treatment after discharge. We confirmed racial/ethnic differences for two practices (inpatient diagnostic imaging and prescription of corticosteroids at discharge); neither is recommended by the 2014 American Academy of Pediatrics guidelines for treatment of bronchiolitis. The causes of these management differences remain unclear, but they support implementation of care pathways for severe bronchiolitis to reduce disparities in care.