Reducing unwarranted chest x-rays in bronchiolitis: Importance of a robust analysis.

AIM: Bronchiolitis is the commonest reason for hospitalisation amongst infants and is often a target for low-value care (LVC) reduction. We aimed to assess the impact of a multifaceted intervention (clinician education, parent engagement, audit-feedback) on rates of chest x-rays (CXR) in bronchiolitis. METHODS: Longitudinal study of CXRs ordered in infants (1-12 months) diagnosed with bronchiolitis in the Emergency Department (ED) of an Australian paediatric hospital between May 2016 and February 2023. We used logistic regression to measure the impact of the intervention on unwarranted CXR orders, controlling for other potential impacting variables such as time, patient characteristics (age/sex), clinical variables (fever, hypoxia, tachypnoea), seasonal factors (month, day of the week, business hours) and time passed since intervention. RESULTS: Ten thousand one hundred and nine infants were diagnosed with bronchiolitis in the ED over the study period, with 939 (9.3%) receiving a CXR, of which 69% (n = 651) were considered unwarranted. Rates of unwarranted CXRs reduced from 7.9% to 5.4% post-intervention (P < 0.0001). Logistic regression showed the intervention had no significant effect (OR 0.89, 95% CI 0.65-1.23) once other variables and underlying time-based trends were accounted for. CONCLUSIONS: Although pre-post rates appeared significantly improved, a robust analysis demonstrated that our multi-faceted intervention was not effective in reducing CXRs in bronchiolitis. The decision to order CXR was associated with clinical features that overlap with pneumonia suggesting ongoing misconceptions regarding the role of CXR for this indication. Our study highlights the value of large electronic medical record datasets and robust methodology to avoid falsely attributing underlying trends to the LVC intervention.

Impact of an Intervention to Reduce Bronchodilator Use in Bronchiolitis - A Time Series Analysis.

BACKGROUND AND OBJECTIVES: International guidelines recommend against the use of bronchodilators in bronchiolitis. Despite attempts to address low value care practices in pediatrics, the literature is still evolving regarding which interventions are most effective in low value care reduction. We aim to assess the impact of a multifaceted intervention on rates of bronchodilator prescription in bronchiolitis. METHODS: With electronic medical record (EMR) data over a 76- month period, we evaluated changes in bronchodilator prescription among infants aged 1 to 12 months diagnosed with bronchiolitis, using interrupted time series analysis, controlling for preintervention prescribing trends. The setting was the emergency department of a large teaching pediatric hospital. The intervention included education, clinician audit-feedback, and an EMR alert, implemented February 2019. The main outcome measure was rate of bronchodilator prescription per month. RESULTS: There were 9576 infants, aged 1 to 12 months, diagnosed in the emergency department with bronchiolitis over the study period. Bronchodilator ordering reduced from 6.9% to 3.2% after the intervention. Once underlying trends were accounted for, the multifaceted intervention was associated with a reduction in the rate of prescribing (inter-rater reliability 0.98, 95% confidence interval 0.96 to 0.99, P = .037). CONCLUSIONS: We found that the multifaceted intervention, including an EMR alert, may be an effective method of reducing low value care prescribing in bronchiolitis, accelerating the reduction of unnecessary care and supporting sustainable change.

Bronchiolitis at a specialist paediatric centre: The electronic medical record helps to evaluate low-value care.

AIM: Low-value care (LVC) is common. We aimed, using infants presenting to a major tertiary paediatric hospital with bronchiolitis between April 2016 and July 2018, to: (i) assess rates of chest X-ray (CXR) and medication use; (ii) identify associated factors; and (iii) measure the harm of not performing these practices. METHODS: We extracted data from the electronic medical record for all children aged 1-12 months given a diagnosis of bronchiolitis in the emergency department. Factors potentially associated with LVC practices were extracted, including patient demographics, ordering physician characteristics, order indication, medications prescribed and admission ward. To assess for harm, a radiologist, blinded to CXR indication, reviewed all CXRs ordered over the winter of 2017 for infants with bronchiolitis. RESULTS: A CXR was ordered for 439 (11.2%) infants, most commonly to rule out consolidation and collapse (65%). CXRs were more likely to be ordered for admitted infants (40.9% admitted to the general medical ward), and 62% were ordered by emergency department staff. Salbutamol was prescribed for 9.3% (n = 199). Amongst those who had a CXR, 28% were prescribed an antibiotic compared to 2.1% for those who did not. In an audit of 98 CXRs ordered over the winter of 2017, there were no CXR findings that meaningfully affected patient outcomes. CONCLUSION: Using electronic medical record data, we found that CXR and medication use in bronchiolitis were higher than expected given our hospital guideline advice. Future research needs to understand why and develop interventions to reduce LVC.