Bronchiolitis is a disorder commonly caused by viral lower respiratory tract infection in infants. It is the most common cause of hospitalization among infants during the first 12 months of life. The diagnosis is made clinically. The disease is usually self-limiting, and treatment in hospital is mainly based around supportive care with oxygen and hydration.
Despite established guidelines internationally based on good evidence for supportive care in the management of bronchiolitis, there is still significant variation in practice between physicians in managing infants with bronchiolitis, with overuse of interventions that have been shown to make little or no difference in disease outcome.
We reviewed the costing data for all patients aged <= 2 years admitted to our unit from January 2016 to December 2017. We excluded patients who were admitted to the intensive care unit or high dependency unit. We also evaluated the following quality indicators: 1) No readmission within 30 days 2) Length of stay (LOS) within 5 days 3) No unnecessary interventions including chest radiology, antibiotics, full blood count or bronchodilator treatment.
With guidance from subject matter experts, an updated departmental practice guideline for bronchiolitis incorporating up-to-date evidence and recommendations was finalized and put into practice in December 2017. We then prospectively reviewed the costing data and the same quality indicators post-implementation from January 2018 to December 2018.
There were 777 cases admitted to our unit from January 2016 to December 2017. The mean hospital cost was $3791. The mean length of stay (LOS) was 4 days. In terms of quality indicators, the main variables which needed improvement were the use of bronchodilators (42% of patients) and chest radiography (18% of patients). This is translated to a 31% baseline clinical quality index (CQI).
Post intervention, our mean cost improved to $3358 (11.4% reduction) while our CQI improved to 44%. Significantly, our mean LOS decreased to 3 days. We also compared the cost variance at the clinician level; this showed a decrease in standard deviation (SD) of mean cost (SD of $8638 in 2017 to $5081 in 2018, p < 0.05), showing that the practice variance had decreased in parallel with a reduction in cost.
.png?sfvrsn=7132d9d_1)
We have seen a steady increase in case volume over the years. In 2023, there were 365 patients with bronchiolitis (meeting the case definition). This increased to 486 in 2024. We maintained a median length of stay of 2 days, median cost of $2756 in 2023 and $2802 in 2024, and clinical quality index (CQI) of 48% in 2023 and 50% in 2024.
