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Group-facilitated audit and feedback to improve bronchiolitis care in the emergency department

  • Shawn K. Dowling (a1) (a2) (a3), Inelda Gjata (a1), Nathan M. Solbak (a1), Colin G.W. Weaver (a4) (a5), Katharine Smart (a2), Robyn Buna (a2) and Antonia S. Stang (a2) (a3) (a4)...

Abstract

Objective

Despite strong evidence recommending supportive care as the mainstay of management for most infants with bronchiolitis, prior studies show that patients still receive low-value care (e.g., respiratory viral testing, salbutamol, chest radiography). Our objective was to decrease low-value care by delivering individual physician reports, in addition to group-facilitated feedback sessions to pediatric emergency physicians.

Methods

Our cohort included 3,883 patients ≤ 12 months old who presented to pediatric emergency departments in Calgary, Alberta, with a diagnosis of bronchiolitis from April 1, 2013, to April 30, 2018. Using administrative data, we captured baseline characteristics and therapeutic interventions. Consenting pediatric emergency physicians received two audit and feedback reports, which included their individual data and peer comparators. A multidisciplinary group-facilitated feedback session presented data and identified barriers and enablers of reducing low-value care. The primary outcome was the proportion of patients who received any low-value intervention and was analysed using statistical process control charts.

Results

Seventy-eight percent of emergency physicians consented to receive their audit and feedback reports. Patient characteristics were similar in the baseline and intervention period. Following the baseline physician reports and the group feedback session, low-value care decreased from 42.6% to 27.1% (absolute difference: −15.5%; 95% CI: −19.8% to −11.2%) and 78.9% to 64.4% (absolute difference: −14.5%; 95% CI: −21.9% to −7.2%) in patients who were not admitted and admitted, respectively. Balancing measures, such as intensive care unit admission and emergency department revisit, were unchanged.

Conclusion

The combination of audit and feedback and a group-facilitated feedback session reduced low-value care for patients with bronchiolitis.

RÉSUMÉObjectif

Malgré les recommandations fondées sur des données probantes solides selon lesquelles la prise en charge de la bronchiolite chez la plupart des nourrissons devrait reposer principalement sur les soins d'entretien, des études démontrent que les patients sont encore soumis à des soins de faible valeur (recherche de virus respiratoires, salbutamol, radiographie pulmonaire, etc.). L’étude visait donc à diminuer le recours aux soins de faible valeur par la remise de rapports individuels aux médecins d'urgence pédiatrique (MUP) ainsi que par la tenue de séances collectives de rétroaction avec animateur.

Méthode

La cohorte comptait 3883 patients âgés de ≤ 12 mois et traités pour une bronchiolite au service des urgences (SU) pédiatriques à Calgary (Canada), du 1er avril 2013 au 30 avril 2018. La collecte de données administratives a permis de dégager les caractéristiques de base et les interventions thérapeutiques. Les MUP consentants ont reçu deux rapports d'audit et de rétroaction, contenant leurs données personnelles ainsi que celles des pairs comparateurs. De plus, on a présenté, au cours d'une séance collective et pluridisciplinaire de rétroaction avec animateur, les données recueillies, de même que les obstacles à la diminution du recours aux soins de faible valeur et les facteurs facilitants. Le principal critère d’évaluation consistait en la proportion de patients soumis à des interventions de faible valeur, quelles qu'elles soient, et des analyses ont été effectuées à l'aide de cartes de contrôle de processus statistique.

Résultats

Au total, 78% des médecins d'urgence ont accepté de recevoir les rapports d'audit et de rétroaction. Les caractéristiques des patients étaient comparables au cours de la période de référence et de la période d'intervention. On a noté, après la remise des premiers rapports aux médecins et la tenue de la séance collective de rétroaction, une diminution de la proportion des soins de faible valeur, qui est passée de 42,6% à 27,1% (différence absolue : −15,5%; IC à 95% : −19,8% à −11,2%) et de 78,9% à 64,4% (différence absolue : −14,5%; IC à 95% : −21,9% à −7,2%) chez les patients non hospitalisés et hospitalisés, respectivement. Les mesures de stabilisation, telles que l'admission au service de soins intensifs ou les reconsultations au SU, sont restées stables.

Conclusion

L'association des rapports d'audit et de rétroaction et de la séance collective de rétroaction avec animateur a permis de réduire le recours aux soins de faible valeur chez les patients souffrant d'une bronchiolite.

Copyright

Corresponding author

Correspondence to: Dr. Shawn K. Dowling, Physician Learning Program, Health Sciences Centre, G-302, University of Calgary, 3330 Hospital Drive NW, Calgary, ABT2N 4N1; Email: shawn.dowling@ucalgary.ca.

References

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1.Friedman, JN, Rieder, MJ, Walton, JM. Bronchiolitis: recommendations for diagnosis, monitoring and management of children one to 24 months of age. Paediatr Child Health 2014;19(9):485–98.
2.Ralston, SL, Lieberthal, AS, Meissner, HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics 2014;134(5):e1474–502.
3.Florin, TA, Byczkowski, T, Ruddy, RM, et al. Variation in the management of infants hospitalized for bronchiolitis persists after the 2006 American Academy of Pediatrics bronchiolitis guidelines. J Pediatr 2014;165(4):786–92.e1.
4.Hartling, L, Bialy, LM, Vandermeer, B, et al. Epinephrine for bronchiolitis. Cochrane Database Syst Rev 2011;6:CD003123.
5.Corneli, HM, Zorc, JJ, Mahajan, P, et al. A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J Med 2007;357(4):331–9.
6.Gadomski, AM, Scribani, MB. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev 2014;6:CD001266.
7.Farley, R, Spurling, GK, Eriksson, L, Del Mar, CB. Antibiotics for bronchiolitis in children under two years of age. Cochrane Database Syst Rev 2014;10:CD005189.
8.Ralston, S, Comick, A, Nichols, E, Parker, D, Lanter, P. Effectiveness of quality improvement in hospitalization for bronchiolitis: a systematic review. Pediatrics 2014;134(3):571–81.
9.Tyler, A, Krack, P, Bakel, LA, et al. Interventions to reduce over-utilized tests and treatments in bronchiolitis. Pediatrics 2018;141(6):e20170485.
10.Gude, WT, Brown, B, Van Der Veer, SN, et al. Clinical performance comparators in audit and feedback: a review of theory and evidence. Implement Sci 2019;14(1):39.
11.Gould, NJ, Lorencatto, F, During, C, et al. How do hospitals respond to feedback about blood transfusion practice? A multiple case study investigation. PLoS One 2018;13(11):e0206676.
12.Colquhoun, HL, Carroll, K, Eva, KW, et al. Advancing the literature on designing audit and feedback interventions: identifying theory-informed hypotheses. Implement Sci 2017;12(1):117.
13.Sprecher, E, Chi, G, Ozonoff, A, et al. Use of social psychology to improve adherence to national bronchiolitis guidelines. Pediatrics 2019;143(1):e20174156.
14.Ogrinc, G, Davies, L, Goodman, D, et al. SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process. BMJ Qual Saf 2016;25(12):986–92.
15.Cooke, LJ, Duncan, D, Rivera, L, et al. A practical, evidence-informed approach for the design and implementation of socially constructed learning interventions using audit and group feedback. Implement Sci 2018;13(1):136.
16.Sargeant, J, Lockyer, J, Mann, K, et al. Facilitated reflective performance feedback: developing an evidence- and theory-based model that builds relationship, explores reactions and content, and coaches for performance change (R2C2). Acad Med 2015;90(12):1698–706.
17.Mohammed, MA, Worthington, P, Woodall, WH. Plotting basic control charts: tutorial notes for healthcare practitioners. Qual Saf Health Care 2008;17(2):137–45.
18.Mohammed, MA, Panesar, JS, Laney, DB, Wilson, R. Statistical process control charts for attribute data involving very large sample sizes: a review of problems and solutions. BMJ Qual Saf 2013;22(4):362–8.
19.Macros, QI. Stability analysis and control chart rules; 2019. Available at: https://www.qimacros.com/control-chart/stability-analysis-control-chart-rules (accessed May 23, 2019).
20.Wagner, AK, Soumerai, SB, Zhang, F, Ross-Degnan, D. Segmented regression analysis of interrupted time series studies in medication use research. J Clin Pharm Ther 2002;27(4):299309.
21.Breakell, R, Thorndyke, B, Clennett, J, Harkensee, C. Reducing unnecessary chest X-rays, antibiotics and bronchodilators through implementation of the NICE bronchiolitis guideline. Eur J Pediatr 2018;177(1):4751.
22.Hester, G, Lang, T, Madsen, L, Tambyraja, R, Zenker, P. Timely data for targeted quality improvement interventions: use of a visual analytics dashboard for bronchiolitis. Appl Clin Inform 2019;10(1):168–74.
23.Mussman, GM, Lossius, M, Wasif, F, et al. Multisite emergency department inpatient collaborative to reduce unnecessary bronchiolitis care. Pediatrics 2018;141(2):e20170830.
24.Gay, JC, Agrawal, R, Auger, KA, et al. Rates and impact of potentially preventable readmissions at children's hospitals. J Pediatr 2015;166(3):613–9.e5.
25.Bryan, MA, Desai, AD, Wilson, L, Wright, DR, Mangione-Smith, R. Association of bronchiolitis clinical pathway adherence with length of stay and costs. Pediatrics 2017;139(3):e20163432.
26.Cheng, AHY, Campbell, S, Chartier, LB, et al. Choosing Wisely Canada: five tests, procedures and treatments to question in emergency medicine. CJEM 2017;19(S2):S9S17.
27.Reiter, J, Breuer, A, Breuer, O, et al. A quality improvement intervention to reduce emergency department radiography for bronchiolitis. Respir Med 2018;137:15.
28.Ivers, N, Jamtvedt, G, Flottorp, S, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012;13(6):CD00259.
29.Brehaut, JC, Colquhoun, HL, Eva, KW, et al. Practice feedback interventions: 15 suggestions for optimizing effectiveness. Ann Intern Med 2016;164(6):435–41.

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Group-facilitated audit and feedback to improve bronchiolitis care in the emergency department

  • Shawn K. Dowling (a1) (a2) (a3), Inelda Gjata (a1), Nathan M. Solbak (a1), Colin G.W. Weaver (a4) (a5), Katharine Smart (a2), Robyn Buna (a2) and Antonia S. Stang (a2) (a3) (a4)...

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