Adherence to a Bronchiolitis Clinical Pathway is Associated with Decreased Length of Stay and Costs

Abstract

Importance: Bronchiolitis is the leading cause of infant hospitalization in the United States. Bronchiolitis clinical pathway implementation may result in more efficient, higher value care. Objective: To examine associations between level of adherence to bronchiolitis clinical pathway recommendations, healthcare utilization and costs. Design: Retrospective cohort study Participants: 267 patients 0-24 months diagnosed with bronchiolitis Setting: A free-standing academic children’s hospital emergency department (ED) and inpatient setting from 12/2009 to 7/2012. Exposure: Clinical pathway adherence was assessed using a standardized scoring system (0-100 scale) for 18 process of care quality measures (6 ED; 12 inpatient) obtained by medical record review. Adherence scores were categorized into low, middle, and high tertiles. Outcomes and Measures: Generalized linear models were used to examine relationships between adherence score tertile and 1) ED and inpatient length of stay (LOS), and 2) costs adjusted for LOS. Logistic regression was used to examine associations between adherence score tertile and 1) need for inpatient admission and 2) ED/inpatient 7-day readmissions. Models were adjusted for age, medical complexity and ED triage acuity. Results: Mean adherence scores were: ED 78.8 (standard deviation [SD] 18.1, n=264), inpatient 95.0 (SD 6.3, n= 216), and combined ED and inpatient 88.6 (SD 9.2, n=267). ED and inpatient LOS were significantly shorter for cases in the highest versus the lowest adherence score tertile (ED: 190 minutes [SD 77] vs 264 minutes [SD 84], p<.001; and inpatient: 2.7 days [SD 1.7] vs 3.6 days [SD 3.0], p<.05). Both ED and inpatient costs were less for cases in the highest versus lowest adherence score tertile (ED: -$97, [95% confidence interval [CI] -$20, -$174; p < .05]; and inpatient: -$1,601 [95% CI -$292, -$2,910; p <.05]). ED cases in the highest tertile had a lower odds of inpatient admission versus cases in the lowest tertile (OR 0.38 [95% CI .15, .97]). Readmissions and ED return visits did not differ by adherence score tertile. Conclusions: High adherence to bronchiolitis clinical pathway recommendations was associated with shorter LOS and lower cost. These reductions did not result in increased readmissions or return ED visits. Using evidence-based standards may reduce unnecessary healthcare utilization.