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Improving Pediatric Respiratory Chest Radiograph Stewardship in a Statewide Network
John A Greco1,2, Michele M Nypaver1,2,3, Keith E Kocher1,3,4
1Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan.
Insights
A quality improvement program significantly reduced chest radiograph (CXR) use in children with respiratory illnesses in emergency departments. This initiative improved stewardship without increasing revisits or significantly altering admission rates.
Area of Science:
- Pediatric Emergency Medicine
- Healthcare Quality Improvement
- Radiology Stewardship
Background:
- Overutilization of chest radiographs (CXRs) in pediatric emergency departments (EDs) for common respiratory conditions is a persistent issue.
- Implementing quality improvement (QI) initiatives and financial incentives can drive changes in clinical practice.
Purpose of the Study:
- To evaluate the impact of a multicomponent QI and financial incentive program on chest radiograph (CXR) stewardship.
- To assess the effect on CXR utilization in children diagnosed with asthma, bronchiolitis, and croup across a statewide emergency network.
Main Methods:
- A statewide QI program was launched in March 2019 to reduce routine CXR use in pediatric respiratory conditions.
- Data from 39 emergency departments (EDs) between May 2017 and April 2023 were analyzed.
- Statistical process control charts assessed trends in CXR use, with ED revisits and admission rates monitored as balancing measures.
Main Results:
- Network-wide CXR use decreased from 34.3% to 21.1% of ED visits for asthma, bronchiolitis, and croup.
- Sites participating in the financial incentive program saw CXR use drop from 32.5% to 19.2%.
- No significant change in ED revisits for respiratory conditions (3.4% vs. 3.6%), with a modest increase in admission rates (21.5% vs. 22.5%).
Conclusions:
- A multicomponent QI initiative coupled with financial incentives effectively reduced statewide ED use of CXRs in children with common respiratory illnesses.
- This program offers a transferable framework for improving diagnostic stewardship in other healthcare systems.
Objective:
To investigate the impact of a multicomponent quality improvement (QI) and financial incentive program on chest radiograph (CXR) stewardship in children with asthma, bronchiolitis, and croup in a statewide emergency network.
Methods:
The Michigan Emergency Department Improvement Collaborative launched a multicomponent QI program in March 2019 to decrease routine CXR use in children with common respiratory conditions. A subset of sites elected to adopt this CXR use metric within a financial incentive program. We analyzed data from visits between May 2017 and April 2023 at 39 emergency departments (EDs). The primary outcome was overall CXR use as a proportion of ED visits for asthma, bronchiolitis, and croup. We aggregated performance monthly at the site level and used statistical process control charts to assess improvement trends. Changes in ED revisits for respiratory conditions within 72 hours and admission rates served as balancing measures.
Results:
A total of 114 238 respiratory visits were included. Network-wide CXR use decreased from 34.3% of all ED respiratory visits at baseline to 21.1%. In sites selecting CXR use as an incentive measure, CXR use decreased from 32.5% to 19.2%. Rates of ED revisits for respiratory conditions did not change from the pre- to postintervention period (3.4% vs 3.6%, P = .22), while admission rates increased only modestly (21.5% vs 22.5%, P < .001).
Conclusion:
ED use of CXR in children with common respiratory conditions decreased statewide after implementation of a multicomponent QI initiative and incentive program, providing a potential framework for improvement in other health care systems.
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