Sustainability in the AAP Bronchiolitis Quality Improvement Project

OBJECTIVES The health care system faces ongoing challenges due to low-value care. Building on the first pediatric hospital medicine contribution to the American Board of Internal Medicine Foundation Choosing Wisely Campaign, a working group was convened to identify additional priorities for improving health care value for hospitalized children. METHODS A study team composed of nominees from national pediatric medical professional societies was convened, including pediatric hospitalists with expertise in clinical care, hospital leadership, and research. The study team surveyed national pediatric hospitalist LISTSERVs for suggestions, condensed similar responses, and performed a literature search of articles published in the previous 10 years. Using a modified Delphi process, the team completed a series of structured ratings of feasibility and validity and facilitated group discussion. The sum of final mean validity and feasibility scores was used to identify the 5 highest priority recommendations. RESULTS Two hundred seven respondents suggested 397 preliminary recommendations, yielding 74 unique recommendations that underwent evidence review and rating. The 5 highest-scoring recommendations had a focus on the following aspects of hospital care: (1) length of intravenous antibiotic therapy before transition to oral antibiotics, (2) length of stay for febrile infants evaluated for serious bacterial infection, (3) phototherapy for neonatal hyperbilirubinemia, (4) antibiotic therapy for community-acquired pneumonia, and (5) initiation of intravenous antibiotics in infants with maternal risk factors for sepsis. CONCLUSIONS We propose that pediatric hospitalists can use this list to prioritize quality improvement and scholarly work focused on improving the value and quality of patient care for hospitalized children.

Section: Discussionmentioning

confidence: 99%

Choosing Wisely in Pediatric Hospital Medicine: 5 New Recommendations to Improve Value

Tchou

Schondelmeyer

Álvarez

et al. 2021

“…Few pediatric QI interventions have examined outcomes .6 months after implementation. 22 Although there are general frameworks for sustaining the benefits of QI interventions, 23 it is still unclear which strategies are most feasible and effective. Understanding this will require sustained data collection and monitoring.…”

Section: Improving Qi Strategy 3: Determine How To Sustain Changementioning

confidence: 99%

Using Quality Improvement to Tackle Unwarranted Practice Variation

Kaiser

Garber

2018

As health care in the United States moves from quantity to quality, unwarranted practice variation has become a natural target for those wishing to improve care. Variation in provider practice should arise from personalizing care decisions on the basis of each patient' s condition and personal preferences. ''Unwarranted'' variation refers to variation beyond what would be expected based on patient or population differences 1 ; it is due to non-evidencebased, inappropriate, and/or inefficient health care. Unwarranted variation in pediatrics has been demonstrated since the early 1900s, when Sir Allison Glover 2 compared pediatric tonsillectomy rates in geographically and demographically similar areas of England. He showed a .10-fold variation in rates and concluded, "A study of the geographical distribution [of tonsillectomy] in children discloses no correlation between any other factor, such as overcrowding , poverty, bad housing, or climate. In fact it defies any explanation, save that of variation of medical opinion on the indications." 2 Despite broad dissemination of evidence-based guidelines for asthma management, 3 unwarranted variation persists in care and outcomes for children treated in emergency departments and/or hospitalized for asthma. Studies have demonstrated wide variation in rates of diagnostic testing (eg, complete blood counts), interventions (eg, intravenous [IV] magnesium sulfate), transfer to ICUs, hospital readmissions, length of stay, and costs, even after correction for patient characteristics. 4-7 This variation is largely due to the challenges of integrating guidelines into care, which may take up to 17 years. 8

“…[12][13][14][15][16][17] Quality improvement efforts focused on bronchiolitis have been effective at decreasing unnecessary care in hospitalbased settings and have predominately focused on reducing laboratory testing, chest radiographs, and albuterol use. [18][19][20][21][22] There has been less focus in quality improvement on the recommendations for what care should be provided on the basis of the American Academy of Pediatrics Clinical Practice Guidelines for bronchiolitis, such as documentation of key historical features and parent education. 11 Additionally, few researchers have examined the success of decreasing unnecessary care and implementation of American Academy of Pediatrics recommendations on outcomes for bronchiolitis such as length of stay (LOS) and cost.…”

mentioning

confidence: 99%

Associations Between Quality Measures and Outcomes for Children Hospitalized With Bronchiolitis

Bryan

Tyler

Zhou

et al. 2020

OBJECTIVES: To use adherence to the Pediatric Respiratory Illness Measurement System (PRIMES) indicators to evaluate the strength of associations for individual indicators with length of stay (LOS) and cost for bronchiolitis. METHODS: We prospectively enrolled children with bronchiolitis at 5 children’s hospitals between July 1, 2014, and June 30, 2016. We examined associations between adherence to each individual PRIMES indicator for bronchiolitis and LOS and cost. Sixteen indicators were included, 9 “overuse” indicators for care that should not occur and 7 “underuse” indicators for care that should occur. We performed mixed effects linear regression to examine the association between adherence to each individual indicator and LOS (hours) and cost (dollars). All models controlled for patient demographics, patient complexity, and hospital. RESULTS: We enrolled 699 participants. The mean age was 8 months; 56% were male, 38% were white, and 63% had public insurance. Three indicators were significantly associated with shorter LOS and lower cost. All 3 indicators were overuse indicators and related to laboratory testing: no blood cultures (adjusted mean difference in LOS: −24.3 hours; adjusted mean cost difference: −$731, P < .001), no complete blood cell counts (LOS: −17.8 hours; cost: −$399, P < .05), and no respiratory syncytial virus testing (LOS: −16.6 hours; cost: −$272, P < .05). Two underuse indicators were associated with higher cost: documentation of oral intake at discharge ($671, P < .01) and documentation of hospital follow-up ($538, P < .05). CONCLUSIONS: A subset of PRIMES quality indicators for bronchiolitis are strongly associated with improved outcomes and can serve as important measures for future quality improvement efforts.