Use of Social Psychology to Improve Adherence to National Bronchiolitis Guidelines.

OBJECTIVES: The American Academy of Pediatrics' bronchiolitis guidelines recommend against albuterol and corticosteroids for treating and chest radiographs (CRs) for diagnosing infants with bronchiolitis. However, high rates of nonadherence have been documented. Our objective was to improve guideline adherence in infants with bronchiolitis. METHODS: This quality improvement study was conducted in 1 urban academic pediatric primary care clinic caring for predominately minority and publicly insured children. We tested provider guideline education, display of guidelines in patient care areas, and monthly e-mails to all providers documenting deviation rates, with individual e-mails to providers who deviated. P-charts and interrupted time series analysis were used to estimate the effect of the intervention. RESULTS: There were 380 children <2 years of age with a diagnosis of bronchiolitis in the 16 nonsummer months preintervention and 417 in the 15 postintervention months. Rates of prescribed and administered albuterol declined from 45.7% in the baseline period to 13.7% in the intervention period and CR use dropped from a mean of 10.1% to 3.4%, both demonstrating special cause variation. Steroid use did not change significantly. In interrupted time series analyses, the intervention was associated with a significant decrease in albuterol use (P < .001) but not in CR or steroid use. Emergency department visits declined slightly but admissions for bronchiolitis were stable. CONCLUSIONS: Traditional quality improvement efforts coupled with social psychology techniques resulted in improved guideline adherence in outpatient bronchiolitis management. Additional study will help identify which techniques are most effective for increasing guideline adherence in cases of low-value care.

Development of a questionnaire to assess the impact on parents of their infant's bronchiolitis hospitalization.

BACKGROUND: Bronchiolitis is a distressing respiratory condition and the most common cause of hospitalization during the first year of life. The hospitalization of an infant is a stressful event for parents and deserves careful consideration. The objective of this work was to develop and validate a self-administered instrument that comprehensively assesses the impact on parents of the hospitalization of their infant for bronchiolitis. METHODS: The Impact of Bronchiolitis Hospitalization Questionnaire (IBHQ©) was developed using a literature review and pre-study interviews with both parents and clinicians. For finalization and psychometric validation, it was included in a multicenter, longitudinal, observational study conducted in France. Parents of infants under the age of 1 year and hospitalized for bronchiolitis were asked to complete the questionnaire at hospital discharge, and 3 months after. RESULTS: Seven hundred and seven questionnaires were completed by the parents of the 463 eligible infants. After finalization, based on principal component analyses, the IBHQ included 30 core items allowing the calculation of 7 dimension core scores (Worries and distress; Fear for future; Guilt; Impact on daily organization; Physical impact; Impact on behavior with hospitalized infant; Financial impact), as well as 16 optional items, allowing the calculation of 5 optional dimension scores (Disturbed breastfeeding; Physical reaction of hospitalized infant; Impact on feeding; Impact on behavior with other infants; Siblings' reaction). Internal consistency reliability and construct validity of the IBHQ were satisfactory. The highest impact was observed for "Worries and distress", "Fear for future" and "Impact on daily organization" scores. CONCLUSIONS: The IBHQ is a reliable and valid instrument for assessing the multifaceted impact on parents of the hospitalization of their infant for bronchiolitis.

Actitud práctica diagnóstica y terapéutica ante la bronquiolitis aguda del lactante en Galicia (estudio Bronquio-Gal) / A practice approach to the diagnosis and treatment of infants with acute bronchiolitis in Galicia, Spain (Bronquio-Gal study)

Introducción: El diagnóstico y el tratamiento de la bronquiolitis aguda son controvertidos. Pretendemos conocer las actitudes prácticas diagnóstico-terapéuticas de los pediatras de Galicia en el contexto de la bronquiolitis aguda y analizar la influencia que puedan tener en la respuesta factures profesionales, como la base formativa, la experiencia práctica y el entorno laboral. Material y métodos: Estudio observacional transversal mediante encuesta postal que incluía un supuesto clínico de bronquiolitis aguda y 40 cuestiones relacionadas. La encuesta se envió a los pediatras miembros de la Sociedad de Pediatría de Galicia en mayo de 2004. Resultados: Untotoal de 103 encuestas fueron devueltas debidamente cumplimentadas. La mita de los participantes (50,5%) tenía una edad superior a los 45 años. El 87% eran pediatras especialistas y el 13% médicos residentes. El 58% de los facultativos desarrollaban su trabajo habitual en el ámbito de la atención primaria. En la mayoría de los casos, la actitud diagnóstica se adecuó a las recomendaciones vigentes, destacando la aplicación de escalas clínicas y la pulsiocimetría. Por el contrario, se indicaron tratamientos farmacológicos con más frecuencia de la recomendable, y algunos fármacos, como broncodilatadores o los corticoides, se empleban de forma casi generalizada. La experiencia práctica no tuvo influencia en las respuestas. El uso de pruebas de detección rápida del virus respiratorio sincitial fue más frecuente entre los médicos residentes (p<0.001). Los pediatras hospitalarios aplicaron con más frecuencia todas las exploraciones complementarias encuestadas (p<0,001), con la excepción de las escalas de valoración clínica, empleadas por igual en ambos grupos. En el ámbito hospitalario se indicaron con más frecuencia la oxigenoterapia y los broncodilatadores y, en particular, la adrenalina (p<0,001). Conclusiones: Hay grandes discrepancias entre la práctica habitual y las evidencias que la justifican. La realización de una conferencia de consenso nacional sobre el tratamientro de la bronquiolitis aguda podría ayudar a mejorar la atención a estos pacientes y racionalizar el consumo de recursos

Introduction: The diagnosis and treatment of acute bronchiolitis are controversial issues. We proposed to assess the practice patterns of pediatricians in Galicia (Northwest Spain) in the diagnosis and treatment of this disease, and to analyze the influence on the response of professional factors such as medical training, practical experience, and work setting. Material and methods: A total of 103 correctly completed surveys were returned. Half of the responders (50,5%) were over 45 years of age. Eighty-seven percent of them were pediatricians and 13% were pediatric residents. In all, 58% of the physicians worked, in the primary care setting. In most cases, the diagnostic approach followed the current international recommendations, with an especially widespread use of clinical scales and pulse oximetry. In contrast, pharmacological therapies were prescribed more frequently than is recommended,a nd the use of drugs such as bronchodilators or corticosteroids was nearly genralized. Practical experience did not influence the responses. Respiratory syncytial virus detection assays were more frequently indicated by medical residens (p<0.001). All the complementary tests included in the survey were requested more frequently by in-hospital pediatricians than by primary care pediatricians (p<0,001) , with the exception of clinical scales, which were employed to a similar extent in both groups. Oxygen therapy, bronchodilator therapy and, in particular, epinephrine were indicated more frequently in the hospital setting (p<0,001). Conclusions: There are considerable discrepancies between routine practice and the evidence justifying it. A national consensus conference on the management of acute bronchiolitis could help to improve patient care and to rationalize the use of resources

At-home recovery following hospitalization for bronchiolitis.

OBJECTIVES: To characterize the at-home recovery of infants after hospitalization for bronchiolitis, the impact of recovery from this illness on the family, and the association between delayed infant recovery and parental satisfaction with hospital care. METHODS: Otherwise healthy infants less than 1 year of age admitted to 6 children's hospitals were eligible. Telephone interviews with 486 parents (85% of sampled), 1-2 weeks following discharge, addressed functional recovery, lingering symptoms, family disruption, returns to the emergency department, and parental recall of satisfaction with care. RESULTS: Two thirds of infants experienced difficulties with normal routines (feeding, sleeping, contentedness, liveliness) on the day of discharge. By 5 days at home, 22% continued to experience disruption in sleeping, and 16% in feeding routines. Coughing (56%) and wheezing (27%) were common 4 to 6 days after discharge. Parents who reported longer delays in return to normal family routines took additional time off work, kept their infants out of day care twice as many days, and were more likely to take their infants to the doctor or hospital for repeat medical care. Parents from families slower to return to a normal routine recalled the hospital stay less favorably. CONCLUSIONS: A small but important proportion of infants have a protracted recovery period following hospitalization for bronchiolitis. Delayed recovery is associated with parental work time loss and less favorable parental impressions of care in the hospital. Anticipatory guidance about home recovery could allow parents to plan for extended home care and improve satisfaction with hospital care.