Bronchiolitis at a specialist paediatric centre: The electronic medical record helps to evaluate low‐value care

Abstract

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.

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

“…The impact of patient characteristics or seasonal factors on rates of CXR in bronchiolitis have not been reported. Our previous study shows males present to hospital with bronchiolitis more frequently than females, suggesting sex differences in illness presentation 18 . Younger children are often considered more vulnerable and are likely to attract more clinical concern.…”

“…4,18 Our earlier study showed that almost 40% of children admitted to the General Medical ward receive a CXR, compared to 3% of those who are discharged home from ED. 18 The impact of patient characteristics or seasonal factors on rates of CXR in bronchiolitis have not been reported. Our previous study shows males present to hospital with bronchiolitis more frequently than females, suggesting sex differences in illness presentation.…”

“…Our previous study shows males present to hospital with bronchiolitis more frequently than females, suggesting sex differences in illness presentation. 18 Younger children are often considered more vulnerable and are likely to attract more clinical concern. As a seasonal illness, most bronchiolitis is seen over winter, with clinicians less likely to be familiar with the guidelines during summer months.…”

“…Severity of illness, as measured by admission to hospital, has been associated with a higher rate of CXR. 4,18 Our earlier study showed that almost 40% of children admitted to the General Medical ward receive a CXR, compared to 3% of those who are discharged home from ED. 18 The impact of patient characteristics or seasonal factors on rates of CXR in bronchiolitis have not been reported.…”

“…In 2018, we analysed rates of CXR use using large datasets extracted from the EMR at our institution (Australia) and demonstrated rates of 11.2%. 18 Of these, 60% were performed to rule out pneumonia and high rates of antibiotic prescribing were seen. Of those ordered a CXR and prescribed antibiotics, only 31% were reported by the radiologist as having evidence of consolidation.…”