Reducing Chest Radiographs in Bronchiolitis Through High-Reliability Interventions

Frazier, Steven Barron; C, Walls; Jain, S. C.; Plemmons, Gregory; Johnson, David

doi:10.1542/peds.2020-014597

Cited by 4 publications

(9 citation statements)

References 21 publications

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“…Education,73–77 audit and feedback,78–82 stakeholder engagement,24 83–86 clinical decision support,87–91 nudge,92–96 clinical champions,97–101 training102–106 and incentives79 107 were the component facets of interventions. Interventions were multifaceted in 79% (113/143) of studies and single faceted in 21% (30/143) of studies.…”

Section: Resultsmentioning

confidence: 99%

What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review

Gangathimmaiah,

Drever,

Evans

et al. 2023

BMJ Open

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ObjectivesLow-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide.DesignA mixed-methods scoping review was conducted using the Arksey and O’Malley framework.Data sourcesMedline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022.Eligibility criteriaPrimary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied.Data extraction and synthesisStudy selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment.ResultsThe search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care.ConclusionHigh-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.

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Section: Resultsmentioning

confidence: 99%

What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review

Gangathimmaiah,

Drever,

Evans

et al. 2023

BMJ Open

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“…These three studies did not account for underlying trends before interventions, nor did they measure sustained change beyond a single season, which in the context of rotating junior staff and single‐touch interventions may be limited. More recently, two studies from USA employed a combination of electronic medical record (EMR) ordersets, clinician education, family engagement and metrics dashboards 16,17 . Both studies look at change over time and demonstrate overall improvement.…”

Section: What Is Already Known On This Topicmentioning

confidence: 99%

“…[13][14][15][16][17] Audit-feedback has been proposed to be more impactful when baseline rates of behaviour are high, therefore our lower rates may have limited the potential impact. 16 The study was impacted by the COVID-19 pandemic, with 2 years of the post-intervention period seeing a much smaller volume of patients presenting due to the success of lock-down measures in Melbourne in preventing usual viral spread. 24 The COVID-19 pandemic also affected our ability to include disposition as a variable in our analysis, as the use of ward beds changed with our short stay ward, the most common admission unit for bronchiolitis, pivoting to and from an isolation ward.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

“…More recently, two studies from USA employed a combination of electronic medical record (EMR) ordersets, clinician education, family engagement and metrics dashboards. 16,17 Both studies look at change over time and demonstrate overall improvement. Neither of these studies consider other factors that may influence ordering behaviour, such as patient demographic data, seasonal variation or illness characteristics.…”

Section: What This Paper Addsmentioning

confidence: 99%

“…Other variables included in the analysis were time since study start in days (to capture underlying time trends independent of the intervention) and the potential predictors listed above. Analyses were conducted using STATA statistical software, version 16.…”

Section: Post-intervention Analysismentioning

confidence: 99%

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Reducing unwarranted chest x‐rays in bronchiolitis: Importance of a robust analysis

Lawrence,

Hiscock,

Voskoboynik

et al. 2024

J Paediatrics Child Health

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AimBronchiolitis 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.MethodsLongitudinal 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.ResultsTen 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.ConclusionsAlthough 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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Impact of an Intervention to Reduce Bronchodilator Use in Bronchiolitis – A Time Series Analysis

Lawrence

Hiscock

Voskoboynik

et al. 2023

Hospital Pediatrics

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BACKGROUND AND OBJECTIVES: International guidelines recommend against the use of bronchodilators in bronchiolitis. Despite attempts to address low value care practices in pediatrics, the literature is still evolving regarding which interventions are most effective in low value care reduction. We aim to assess the impact of a multifaceted intervention on rates of bronchodilator prescription in bronchiolitis. METHODS: With electronic medical record (EMR) data over a 76- month period, we evaluated changes in bronchodilator prescription among infants aged 1 to 12 months diagnosed with bronchiolitis, using interrupted time series analysis, controlling for preintervention prescribing trends. The setting was the emergency department of a large teaching pediatric hospital. The intervention included education, clinician audit-feedback, and an EMR alert, implemented February 2019. The main outcome measure was rate of bronchodilator prescription per month. RESULTS: There were 9576 infants, aged 1 to 12 months, diagnosed in the emergency department with bronchiolitis over the study period. Bronchodilator ordering reduced from 6.9% to 3.2% after the intervention. Once underlying trends were accounted for, the multifaceted intervention was associated with a reduction in the rate of prescribing (inter-rater reliability 0.98, 95% confidence interval 0.96 to 0.99, P = .037). CONCLUSIONS: We found that the multifaceted intervention, including an EMR alert, may be an effective method of reducing low value care prescribing in bronchiolitis, accelerating the reduction of unnecessary care and supporting sustainable change.

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Reducing Chest Radiographs in Bronchiolitis Through High-Reliability Interventions

Cited by 4 publications

References 21 publications

What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review

What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review

Reducing unwarranted chest x‐rays in bronchiolitis: Importance of a robust analysis

Impact of an Intervention to Reduce Bronchodilator Use in Bronchiolitis – A Time Series Analysis

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