Successful Chest Radiograph Reduction by Using Quality Improvement Methodology for Children With Asthma

Implementation of an asthma clinical practice guideline did not achieve desired chest radiograph (CXR) usage goals. We attempt to use quality improvement methodology to decrease the percentage of CXRs obtained for pediatric patients with acute asthma exacerbations from 29.3% to <20% and to evaluate whether decreases in CXR use are associated with decreased antibiotic use.

We included all children ≥2 years old at our children's hospital with primary billing codes for asthma from May 2013 to April 2017. A multidisciplinary team tested targeted interventions on the basis of 3 key drivers aimed at reducing CXRs. We used statistical process control charts to study measures. The primary measure was the percentage of patients with an acute asthma exacerbation who were undergoing a CXR. The secondary measure was percentage of patients receiving systemic antibiotics. Balancing measures were all-cause, 3-day return emergency department visits and the percentage of pneumonia and/or asthma codiagnosis encounters.

We included 6680 consecutive patients with 1539 CXRs. Implementation of an asthma clinical practice guideline was associated with decreased CXR use from 29.3% to 23.0%. Targeted interventions were associated with further reduction to 16.0%. For subset analyses, CXR use decreased from 21.3% to 12.5% for treat-and-release patients and from 53.5% to 31.1% for admitted patients. Antibiotic use varied slightly without temporal association with interventions or CXR reduction. There were no adverse changes in balancing measures.

Quality improvement methodology and targeted interventions are associated with a sustained reduction in CXR use in pediatric patients with acute asthma exacerbations. Reduction of CXRs is not associated with decreased antibiotic use.