Using a standardised protocol was effective in reducing hospitalisation and treatment use in children with newly diagnosed immune thrombocytopenia

Abstract

Aim: Childhood immune thrombocytopenia (ITP) has been associated with low bleeding rates and a high frequency of spontaneous remission. Although current guidelines suggest that most patients are just observed, children still receive platelet-enhancing therapies for fear of bleeding complications. We hypothesised that a standardised protocol with a stepdown approach would reduce hospitalisation and treatment use.Method: A retrospective chart review was performed on patients diagnosed with acute ITP between January 2010 and December 2014, before (n = 54) and after (n = 37) the standardised protocol, which was introduced in January 2013. Management and events during the first 3 months following diagnosis were recorded. Results:The protocol resulted in a 34% decrease in the hospitalisation rate (p < 0.001) at diagnosis. Prednisone treatment duration at diagnosis was also significantly reduced (13.1 versus 5.8 days, p = 0.004). Children over 3 years of age were 3.8 times less likely to be hospitalised (95% CI 1.94-7.61) and 2.3 times less likely to receive treatment (95% CI 1.2-4.3). There was no difference in the rate of persistent ITP (38% versus 30%, p = 0.43) or serious bleeding complications (7% versus 5%, p = 0.70).

Change Theory Contributes to Choosing Wisely for Immune Thrombocytopenia

“…Finally, methodologically, they attempted to apply Buchanan bleeding scores to the patients during the retrospective chart review, whereas we chose a simpler approach to defining UT that mirrored our treatment guideline. 4 There were several barriers to implementation. The most significant barrier was physician past experience.…”

“…There are rare single-center examples of successful reduction in aITP treatment by changing inpatient provider practice. 4,5 However, these success stories have not led to broad practice change. Pediatric Health Information System (PHIS) data revealed that .90% of children with aITP presenting to freestanding children' s hospitals are treated despite only 14% having bleeding symptoms.…”

Highlights in this issue

“…Although current guidelines suggest that most patients are just observed, children still receive platelet-enhancing therapy because of concerns about complications related to bleeding. Labrosse et al report that introducing a standardised protocol with a step-down approach reduced hospitalisation and the length of prednisolone treatment in children with newly diagnosed ITP, without any increase in disease complications (9). Ljung comments on the findings (10).…”

The care of a child with a newly diagnosed immune thrombocytopenia

“…The modification increased the notreatment percentage of this milder subgroup from 40 to 74%. Like the paper of Labrosse et al above (9), it shows that it is worthwhile to modify and present consensus data from extensive more academic guidelines to a more userfriendly format for the clinician. Hopefully, such papers will stimulate the creation of local guidelines and flow-sheets to better help the paediatrician choose the recommended noninterventional approaches when these are indicated.…”

“…It is in the context that the recent paper by Labrosse et al published in Acta Paediatrica should be discussed (9). This paper presents the experience of a standardised protocol flow sheet, with a step-down approach to guide decisions on hospitalisation and treatment of ITP in children.…”