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Reducing unwarranted chest x-rays in bronchiolitis: Importance of a robust analysis
Joanna Lawrence1,2,3,4, Harriet Hiscock2,3, Alice Voskoboynik5
1Hospital in the Home, Royal Children's Hospital, Melbourne, Victoria, Australia.
Insights
A multifaceted intervention did not significantly reduce chest x-rays (CXR) in infants with bronchiolitis. Robust analysis revealed underlying trends, not the intervention, influenced CXR rates, highlighting the need for careful methodology in low-value care reduction studies.
Area of Science:
- Pediatric Emergency Medicine
- Health Services Research
- Quality Improvement
Background:
- Bronchiolitis is a leading cause of infant hospitalization and a target for reducing low-value care (LVC).
- Chest x-rays (CXRs) are frequently used in bronchiolitis management but are often deemed unnecessary.
- Multifaceted interventions combining clinician education, parent engagement, and audit-feedback are employed to reduce LVC.
Purpose of the Study:
- To evaluate the impact of a multifaceted intervention on the rates of chest x-rays (CXRs) ordered for infants diagnosed with bronchiolitis.
- To assess the effectiveness of clinician education, parent engagement, and audit-feedback in reducing unwarranted CXR utilization in pediatric emergency departments.
Main Methods:
- A longitudinal study analyzed CXRs ordered for infants (1-12 months) with bronchiolitis in an Australian pediatric hospital ED from May 2016 to February 2023.
- Logistic regression was used to determine the intervention's impact on unwarranted CXR orders, controlling for clinical, seasonal, and temporal variables.
- Data from 10,109 infants were analyzed, with 939 (9.3%) receiving CXRs, 69% of which were deemed unwarranted.
Main Results:
- Pre-intervention, unwarranted CXR rates were 7.9%, decreasing to 5.4% post-intervention (P < 0.0001).
- However, logistic regression indicated the multifaceted intervention had no significant effect (OR 0.89, 95% CI 0.65-1.23) after accounting for confounding variables and time trends.
- Clinical features overlapping with pneumonia were associated with CXR decisions, suggesting persistent misconceptions about CXR utility.
Conclusions:
- Despite apparent pre-post improvements, the multifaceted intervention was ineffective in reducing CXRs for bronchiolitis when rigorously analyzed.
- The study underscores the importance of robust methodology and large electronic medical record datasets to differentiate intervention effects from underlying temporal trends in LVC reduction initiatives.
- Misconceptions regarding the diagnostic utility of CXRs in bronchiolitis persist, necessitating targeted strategies beyond the tested multifaceted approach.
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.
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