Reducing unnecessary chest X-rays, antibiotics and bronchodilators through implementation of the NICE bronchiolitis guideline

Breakell, Richard; Thorndyke, Benjamin; Clennett, Julie; Harkensee, Christian

doi:10.1007/s00431-017-3034-5

Cited by 44 publications

(49 citation statements)

References 10 publications

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“…Our rates of CXR use compare favourably with reported benchmarks in the USA of 20–40% but do not meet those achieved by a UK paediatric centre of 4% . Although target rates are difficult to establish, this benchmark study suggests that rates of 4% are achievable and realistic.…”

Section: Discussioncontrasting

confidence: 66%

“…Our rates of CXR use compare favourably with reported benchmarks in the USA of 20-40% 10,14 but do not meet those achieved by a UK paediatric centre of 4%. 11 Although target rates are difficult to establish, this benchmark study suggests that rates of 4% are achievable and realistic. Our study has demonstrated that reducing rates of CXR to this level would be unlikely to lead to any significant missed diagnoses but requires replication in other settings.…”

Section: Discussionmentioning

confidence: 89%

“…10 In the UK, following the implementation of guidelines reinforced with a clinician educational intervention, one paediatric hospital managed to reduce CXR rates from 12 to 4%. 11 World-wide guidelines, updated in 2016, also recommend strongly against the use of bronchodilators in bronchiolitis. Evidence, based on over 2000 participants younger than 1 year of age in 31 randomised controlled trials who presented with bronchiolitis based on clinical symptoms such as cough, wheeze and coryza, demonstrates that harms outweigh benefit.…”

Section: What This Paper Addsmentioning

confidence: 99%

“…In US centres where interventions to reduce the rate of CXR‐ordering practices have been implemented, rates remain in excess of 20% . In the UK, following the implementation of guidelines reinforced with a clinician educational intervention, one paediatric hospital managed to reduce CXR rates from 12 to 4% …”

mentioning

confidence: 99%

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

Lawrence

Andrew

Bracken

et al. 2019

J Paediatrics Child Health

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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.

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Section: Discussioncontrasting

confidence: 66%

Section: Discussionmentioning

confidence: 89%

Section: What This Paper Addsmentioning

confidence: 99%

mentioning

confidence: 99%

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

Lawrence

Andrew

Bracken

et al. 2019

J Paediatrics Child Health

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“…Antibiotic treatment does not improve the clinical outcomes of viral infections [31]. Decreasing the use of unnecessary antibiotics is the key to combating AMR, and accurate and rapid diagnosis is crucial to decrease antibiotic prescriptions with a minimized risk [9,10,32]. The present study demonstrates that PCR has higher detectability for respiratory viruses compared to traditional antigen tests and viral cultures.…”

Section: Discussionmentioning

confidence: 70%

Increased Detection of Viruses in Children with Respiratory Tract Infection Using PCR

Lin

Hwang

Chiu

et al. 2020

IJERPH

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Respiratory viruses are a common cause of respiratory tract infection (RTI), particularly in neonates and children. Rapid and accurate diagnosis of viral infections could improve clinical outcomes and reduce the use of antibiotics and treatment sessions. Advances in diagnostic technology contribute to the accurate detection of viruses. We performed a multiplex real-time polymerase chain reaction (PCR) to investigate the viral etiology in pediatric patients and compared the detection rates with those determined using traditional antigen tests and virus cultures. Fifteen respiratory viruses were included in our investigation: respiratory syncytial virus A/B (RSV), influenza virus A (FluA) and influenza virus B (FluB), human metapneumovirus (MPV), enterovirus (EV), human parainfluenza virus (PIV) types 1-4, human rhinovirus (RV), human coronavirus OC43, NL63, and 229E, human adenovirus (ADV), and human bocavirus (Boca). In total, 474 specimens were collected and tested. Respiratory viruses were detected more frequently by PCR (357, 75.3%) than they were by traditional tests (229, 49.3%). The leading pathogens were RSV (113, 23.8%), RV (72, 15.2%), PIV3 (53, 11.2%), FluA (51, 10.8%), and ADV (48, 10.1%). For children younger than 5 years, RSV and RV were most prevalent; for children older than 5 years, FluA and ADV were the most frequently detected. Of the specimens, 25.8% (92/357) were coinfected with two or more viruses. RV, Boca, PIV2, FluB, and PIV4 had higher rates of coinfection; MPV and PIV1 had the lowest rates of coinfection (9.1% and 5.3%). To conclude, the detection power of PCR was better than that of traditional antigen tests and virus cultures when considering the detection of respiratory viruses. RSV and RV were the leading viral pathogens identified in the respiratory specimens. One-quarter of the positive specimens were coinfected with two or more viruses. In the future, further application of PCR may contribute to the rapid and accurate diagnosis of respiratory viruses and could improve patient outcomes.

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Trends Over Time in Use of Nonrecommended Tests and Treatments Since Publication of the American Academy of Pediatrics Bronchiolitis Guideline

et al. 2021

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IMPORTANCE Acute viral bronchiolitis is a common and costly pediatric condition for which clinical practice guidelines discourage use of diagnostic tests and therapies. OBJECTIVE To evaluate trends over time for use of nonrecommended services for bronchiolitis since publication of the American Academy of Pediatrics clinical practice guideline on bronchiolitis (originally published in October 2006 and updated in November 2014). DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted using interrupted timeseries regression analysis adjusting for the hospital providing service, patient demographic characteristics, and payer, with 2014 guideline update publication as the event point. Included patients were children younger than 2 years old discharged from the emergency department (ED) or hospital inpatient setting with a primary diagnosis of bronchiolitis at US Children's Hospitals contributing data to the Pediatric Health Information Systems database. Data were analyzed from June through December 2020. MAIN OUTCOMES AND MEASURES Rates of nonrecommended tests (ie, chest radiography, viral testing, and complete blood cell count) and treatments (ie, bronchodilators, corticosteroids, antibiotics) were measured. RESULTS Among 602 375 encounters involving children with a primary diagnosis of bronchiolitis, 404 203 encounters (67.1%) were ED discharges and 198 172 encounters (32.9%) were inpatient discharges; 468 226 encounters (77.7%) involved children younger than 12 months, and 356 796 encounters (59.2%) involved boys. In the period after initial guideline publication (ie, November 2006 to November 2014), a negative use trajectory was found in all measures except viral testing in the ED group. Using the 2014 guideline update as the event point, several measures showed decreased use between study time periods. The greatest decrease was in bronchodilator use, which changed by −13.5 percentage points in the ED group (95% CI, −15.2 percentage points to −11.8 percentage points) and −11.3 percentage points in the inpatient group (95% CI, −13.1 percentage points to −9.4 percentage points). In the period after the 2014 guideline update (ie, December 2014 to December 2019), bronchodilators also showed the greatest change in usage trajectory, steepening more than 2-fold in both groups. In the ED group, the negative trajectory steepened from −0.11% monthly (95% CI, −0.13% to −0.09%) in the first guideline period to a new mean monthly slope of −0.26% (95% CI, −0.30% to −0.23%). In the inpatient group, the mean monthly slope steepened from −0.08% (95% CI, −0.10 to −0.05%) to −0.26% (95% CI, 0.30% to −0.22%). Length of stay decreased from 2.0 days (95% CI, 1.9 days to 2.1 days) to 1.7 days (95% CI, 1.7 days to 1.8 days). Hospital admission rate decreased from 18.0% (95% CI, 13.8% to 22.2%) to 17.8% (95% CI, 13.6 to 22.1%).

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Reducing unnecessary chest X-rays, antibiotics and bronchodilators through implementation of the NICE bronchiolitis guideline

Cited by 44 publications

References 10 publications

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

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

Increased Detection of Viruses in Children with Respiratory Tract Infection Using PCR

Trends Over Time in Use of Nonrecommended Tests and Treatments Since Publication of the American Academy of Pediatrics Bronchiolitis Guideline

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