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Effectiveness of quality improvement in hospitalization for bronchiolitis: a systematic review
Shawn Ralston1, Allison Comick2, Elizabeth Nichols3
1Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire shawn.l.ralston@hitchcock.org.
Insights
Quality improvement strategies significantly reduce unnecessary testing and medication for infants hospitalized with bronchiolitis. These interventions lower bronchodilator, steroid, and antibiotic use, improving care without reported harms.
Area of Science:
- Pediatrics
- Healthcare Quality Improvement
- Infectious Diseases
Background:
- Bronchiolitis is a leading cause of hospitalization for young children in the US, accounting for nearly 20% of acute care admissions.
- Current practices often involve unnecessary diagnostic tests and medications, increasing healthcare costs without improving patient outcomes.
Purpose of the Study:
- To systematically review the quality improvement (QI) literature for inpatient bronchiolitis management.
- To establish benchmarks for reducing unnecessary care in hospitalized infants with bronchiolitis.
Main Methods:
- A comprehensive literature search was conducted across multiple databases (Medline, CINAHL, Cochrane Library).
- Included studies focused on QI interventions versus usual care in hospitalized children under two years of age.
- Data were extracted, confirmed, and pooled using a random effects model to calculate benchmarks.
Main Results:
- Fourteen studies involving over 12,000 infants were analyzed.
- QI interventions led to significant reductions in bronchodilator use (16% fewer patients exposed to repeated doses) and steroid exposure (5 per 100).
- Reductions were also observed in chest radiography (9 per 100) and antibiotic use (4 per 100), with no reported harms.
Conclusions:
- Quality improvement strategies effectively decrease rates of unnecessary care for hospitalized children with viral bronchiolitis.
- Established benchmarks for care include: repeated bronchodilator use (16%), steroid use (1%), chest radiography (42%), and antibiotic use (17%).
- Further research is needed to identify specific characteristics of effective QI interventions due to study heterogeneity.
Background:
Bronchiolitis causes nearly 20% of all acute care hospitalizations for young children in the United States. Unnecessary testing and medication for infants with bronchiolitis contribute to cost without improving outcomes.
Objectives:
The goal of this study was to systematically review the quality improvement (QI) literature on inpatient bronchiolitis and to propose benchmarks for reducing unnecessary care.
Methods:
Assisted by a medical librarian, we searched Medline, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library. Studies describing any active QI intervention versus usual care in hospitalized children <2 years of age were included. Data were extracted and confirmed by multiple investigators and pooled by using a random effects model. Benchmarks were calculated by using achievable benchmarks of care methods.
Results:
Fourteen studies involving >12000 infants were reviewed. QI interventions resulted in 16 fewer patients exposed to repeated doses of bronchodilators per 100 hospitalized (7 studies) (risk difference: 0.16 [95% confidence interval: 0.11-0.21]) and resulted in 5.3 fewer doses of bronchodilator given per patient (95% confidence interval: 2.1-8.4). Interventions resulted in fewer hospitalized children exposed to steroids (5 per 100), chest radiography (9 per 100), and antibiotics (4 per 100). No significant harms were reported. Benchmarks derived from the reported data are: repeated bronchodilator use, 16%; steroid use, 1%; chest radiography use, 42%; and antibiotic use, 17%. The study's heterogeneity limited the ability to classify specific characteristics of effective QI interventions.
Conclusions:
QI strategies have been demonstrated to achieve lower rates of unnecessary care in children hospitalized with viral bronchiolitis than are the norm.