Researchers randomized 26 hospitals providing tertiary or secondary pediatric care in Australia and New Zealand 1:1 to either implement interventions designed to better promote evidence-based care for bronchiolitis or to maintain usual approaches to education around bronchiolitis treatment.
At implementation hospitals, targeted interventions included clinical leads, stakeholder meetings, train-the-trainer workshops, educational intervention delivery, use of other educational materials, and audit and feedback. The goal of these combined efforts was to promote behavior changes that supported evidence-based bronchiolitis care in the emergency department and pediatric inpatient units.
Control hospitals, meanwhile, received printed and electronic copies of the Australian bronchiolitis guidelines without any supports to encourage dissemination or adoption. Researchers didn't collect any information on how guideline information was communicated at control hospitals to avoid the possibility of triggering the Hawthorne effect and influencing the outcomes.
The research team analyzed data on 8,003 infants treated over three bronchiolitis seasons (2014 to 2016) before the implementation period and on 3,727 infants treated over the implementation period (May 1 to November 30, 2017).
The primary outcome was the proportion of infants whose treatment complied with Australian guidelines recommending against five treatments in the first 24 hours of hospitalization: no use of chest radiography, albuterol, glucocorticoids, antibiotics, or epinephrine.
For the three years before the implementation period, compliance ranged from 64% to 73% at implementation hospitals and 60% to 66% at control hospitals.
During the implementation period, 85.1% of infants treated at intervention hospitals achieved the primary outcome, compared with 73.0% in control hospitals, researchers report in JAMA Pediatrics.
Researchers didn't find a statistically significant difference in median length of stay for bronchiolitis between the intervention and control hospitals during the implementation period. No infants died during the study.
"In order to de-implement low-value care we need to first understand barriers and enablers of care, and then develop targeted interventions, built on robust behavioral change models, to address these," said senior study author Stuart Dalziel, director of emergency medical research at Starship Children's Hospital in Auckland, New Zealand.
"This approach can be used to improve care for other high volume conditions where we see considerable clinical variation in care and with clearly established clinical guidelines on appropriate management," Dalziel said by email.
One limitation of the study is that hospitals had to treat at least 135 bronchiolitis cases annually for eligibility, making it possible that the results aren't generalizable to all hospitals. Researchers also included only cases when bronchiolitis was both the emergency department diagnosis and the final diagnosis, excluding cases when a patient with bronchiolitis had chest radiography misinterpreted as bronchopneumonia, the study team notes.
Even so, the study results underscore that implementation of appropriate treatment for bronchiolitis can be accelerated if done systematically, said Dr. Håvard Ove Skjerven, of the pediatric division of allergy and pulmonary diseases at Oslo University Hospital in Norway.
In the case of bronchiolitis, the take home message for clinicians is that the evidence supports less treatment, not more, Dr. Skjerven, who wasn't involved in the study, said by email.
"There is no documentation that supports the effect of any specific medication, and management should be supportive only," Dr. Skjerven said. "This strategy saves resources, makes it easier to hold focus on the vital parameters that matter, and you are less likely to do harm."
SOURCE: https://bit.ly/2QiiEaK JAMA Pediatrics, online April 12, 2021.
By Lisa Rapaport
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