Effectiveness of Targeted Interventions on Treatment of Infants With Bronchiolitis

Abstract

In developed countries, bronchiolitis is the most common reason for infants to be admitted to the hospital, and all international bronchiolitis guidelines recommend supportive care; however, significant variation in practice continues with infants receiving non-evidence-based therapies. Deimplementation research aims to reduce the use of low-value care, and advancing science in this area is critical to delivering evidence-based care.OBJECTIVE To determine the effectiveness of targeted interventions vs passive dissemination of an evidence-based bronchiolitis guideline in improving treatment of infants with bronchiolitis.DESIGN, SETTING, AND PARTICIPANTS This international, multicenter cluster randomized clinical trial included 26 hospitals (clusters) in Australia and New Zealand providing tertiary or secondary pediatric care (13 randomized to intervention, 13 to control) during the 2017 bronchiolitis season. Data were collected on 8003 infants for the 3 bronchiolitis seasons (2014-2016) before the implementation period and 3727 infants for the implementation period (2017 bronchiolitis season, May 1-November 30). Data were analyzed from November 16, 2018, to December 9, 2020.INTERVENTIONS Interventions were developed using theories of behavior change to target key factors that influence bronchiolitis management. These interventions included site-based clinical leads, stakeholder meetings, a train-the-trainer workshop, targeted educational delivery, other educational and promotional materials, and audit and feedback. MAIN OUTCOMES AND MEASURESThe primary outcome was compliance during the first 24 hours of care with no use of chest radiography, albuterol, glucocorticoids, antibiotics, and epinephrine, measured retrospectively from medical records of randomly selected infants with bronchiolitis who presented to the hospital. There were no patient-level exclusions.RESULTS A total of 26 hospitals were randomized without dropouts. Analysis was by intention to treat. Baseline data collected on 8003 infants for 3 bronchiolitis seasons (2014)(2015)(2016) before the implementation period were similar between intervention and control hospitals. Implementation period data were collected on 3727 infants, including 2328 boys (62%) and 1399 girls (38%), with a mean (SD) age of 6.0 (3.2) months. A total of 459 (12%) were Māori (New Zealand), and 295 (8%) were Aboriginal/Torres Strait Islander (Australia). Compliance with recommendations was 85.1% (95% CI, 82.6%-89.7%) in intervention hospitals vs 73.0% (95% CI, 65.3%-78.8%) in control hospitals (adjusted risk difference, 14.1%; 95% CI, 6.5%-21.7%; P < .001).CONCLUSIONS AND RELEVANCE Targeted interventions led to improved treatment of infants with bronchiolitis. This study has important implications for bronchiolitis management and the development of effective interventions to deimplement low-value care.TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry: ACTRN12616001567415.

Development of targeted, theory-informed interventions to improve bronchiolitis management

“…Subsequent to the development of these interventions they have been robustly assessed in a multi-centre cluster randomised controlled trial (cRCT) involving 26 hospitals. Results from our trial demonstrated a 14.1% risk difference favouring the intervention group in compliance to five key bronchiolitis guideline recommendations, measurably improving the management of infants with bronchiolitis [25,26].…”

“…This paper illustrates the stepped, theory and evidence informed process undertaken to develop targeted interventions aiming to improve the management of infants with bronchiolitis. The effectiveness of the six interventions developed has been robustly assessed via a multicentre cRCT [26]. In this trial of 26 hospitals during the 2017 bronchiolitis season (May to November), with data from 3727 infants, the interventions were shown to improve bronchiolitis management by 14.1% (95% CI 6.5 to 21.7%) in hospitals randomised to the interventions compared to control hospitals who undertook usual dissemination practices of the Australasian Bronchiolitis Guideline [26].…”

“…The effectiveness of the six interventions developed has been robustly assessed via a multicentre cRCT [26]. In this trial of 26 hospitals during the 2017 bronchiolitis season (May to November), with data from 3727 infants, the interventions were shown to improve bronchiolitis management by 14.1% (95% CI 6.5 to 21.7%) in hospitals randomised to the interventions compared to control hospitals who undertook usual dissemination practices of the Australasian Bronchiolitis Guideline [26]. This absolute change in care of infants with bronchiolitis is at the upper end of improvements shown in implementation cRCTs [38] and EPOC systematic reviews focusing on the effectiveness of interventions, predominantly to implement care, across healthcare settings [31][32][33][34][35][36] (Additional Table 1).…”

“…Our stepped design successfully incorporated the first three phases described in the CWDF: Phase 0, identification of potential areas of low-value healthcare; Phase 1, identification of local priorities for implementation recommendations; and Phase 2, identification of barriers to implementing recommendations and potential interventions to overcome these. Phase 3, rigorous evaluation of the intervention, has been subsequently undertaken with robust evaluation of our interventions in a cRCT [26]. Phase 4 involves broad dissemination to all similar clinical settings.…”

Avoid doing chest x rays in infants with typical bronchiolitis

“…Targeted quality improvement strategies—which include clinical champions, focused educational delivery, educational materials, and audit and feedback—are effective in de-implementing chest x rays in bronchiolitis 17. Examples of implementation of local clinical pathways based on national guidelines have achieved lower rates of unnecessary chest x rays, although which specific individual intervention is most effective is unclear 1819.…”