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Bronchiolitis at a specialist paediatric centre: The electronic medical record helps to evaluate low-value care
Joanna G Lawrence1,2,3, Lauren Andrew1, Jenny Bracken4
1Informatics and Training, The Royal Children's Hospital, Melbourne, Victoria, Australia.
Insights
Chest X-rays and medications for infant bronchiolitis were frequently used, despite guidelines. This low-value care (LVC) did not show significant harm in a review, indicating a need for intervention.
Area of Science:
- Pediatric Emergency Medicine
- Respiratory Illness
- Health Services Research
Background:
- Low-value care (LVC) is prevalent in pediatric healthcare.
- Bronchiolitis is a common respiratory infection in infants.
- Adherence to clinical guidelines for bronchiolitis management can be variable.
Purpose of the Study:
- To assess the rates of chest X-ray (CXR) and medication use in infants diagnosed with bronchiolitis.
- To identify factors associated with the utilization of LVC practices in bronchiolitis care.
- To evaluate the potential harm resulting from the non-performance of certain LVC practices.
Main Methods:
- Retrospective electronic medical record review of infants (1-12 months) with bronchiolitis.
- Data extraction included patient demographics, physician characteristics, and prescribed treatments.
- Radiologist review of CXRs to assess impact on patient outcomes, blinded to indication.
Main Results:
- Chest X-rays (CXRs) were performed in 11.2% of infants, primarily to rule out consolidation or collapse.
- CXRs were more frequent in admitted infants and those treated by emergency department staff.
- Antibiotic prescription was significantly higher in infants who received a CXR (28%) compared to those who did not (2.1%).
- An audit of 98 CXRs revealed no findings that meaningfully altered patient outcomes.
Conclusions:
- Chest X-ray and medication use in infant bronchiolitis cases exceeded expected rates based on hospital guidelines.
- Current practices suggest a higher-than-necessary utilization of LVC in bronchiolitis management.
- Further research is required to understand the drivers of LVC and develop targeted interventions.
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.
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