Factors associated with salbutamol overuse in bronchiolitis.

Numerous studies have shown that quality improvement methods can reduce the use of medications in the management of bronchiolitis. Our objective is to identify factors related to the overuse of salbutamol in the treatment of bronchiolitis before and after an improvement initiative. Observational study of sociodemographic and clinical factors associated with the use of salbutamol in children diagnosed with bronchiolitis. This was a secondary analysis of a prospective cohort study conducted at 135 primary care (PC) centers and eight pediatric emergency departments (ED) in the Osakidetza/Basque Health Service (Spain) in two epidemic seasons between which a bronchiolitis integrated care pathway (BICP) had been implemented: pre-intervention season from October 2018 to March 2019 and post-intervention season from October 2019 to March 2020. Generalized linear mixed models were used to estimate association of studied variables on use of salbutamol over the two seasons. Four thousand one hundred thirty-four ED attendances and 8573 PC visits were included, of which 1936 (46.8%). And 4067 (47.4%) occurred in the post-intervention period respectively. Six independent risk factors were associated with overuse of salbutamol in both seasons: age ≥ 1 year, aOR 2.32 (2.01 to 2.68) in PC centers, and aOR 6.84 (4.98 to 9.39) in EDs; being seen in the last third of the bronchiolitis season, aOR 1.82 (1.51 to 2.18) in PC centers and aOR 1.78 (1.19 to 2.64) in EDs; making more than one visit to the PC center, aOR 4.18 (3.32 to 5.27) or the ED, aOR 2.06 (1.59 to 2.66); being seen by a general practitioner, aOR 1.97 (1.58 to 2.46) in PC centers; and having a more severe episode, aOR 3.01 (1.89 to 4.79) in EDs.     Conclusion:There are factors associated with salbutamol overuse in children diagnosed with bronchiolitis in PC and emergency settings that persist after the deployment of quality improvement initiatives. What is Known: • Quality improvement initiatives have been shown to decrease the use of non-evidence-based treatments and testing in bronchiolitis. • The magnitude and pattern of change in the use of medications linked to the quality improvement initiatives are not uniform across the same health service. What is New: • Children diagnosed with bronchiolitis ≥ 1 year of age, seen in the last third of the bronchiolitis season, attending more than once, treated by a general practitioner, and/or with more severe episodes are more likely to be treated with salbutamol. • These factors may remain present despite the implementation of improvement initiatives focused on reducing the use of medications in the management of bronchiolitis.

Reducing Unnecessary Treatment of Bronchiolitis Across a Large Regional Health Service in Spain.

OBJECTIVES: A bronchiolitis integrated care pathway (BICP) proved useful in reducing the use of unnecessary medications at a local level. The aim of this study was to reduce overtreatment by scaling up the BICP across our regional health service in the 2019 and 2020 bronchiolitis season. METHODS: We conducted a quality improvement (QI) initiative in 115 primary care (PC) centers and 7 hospitals in the Basque Country, Spain, from October 2019 to March 2020. The primary outcome measure was the percentage of children prescribed salbutamol comparing the rate to that in the previous bronchiolitis season (October 2018-March 2019). Secondary outcomes were the use of other medications. Balancing measures were hospitalization and unscheduled return rates. RESULTS: We included 8153 PC visits, 3424 emergency department (ED) attendances, and 663 inpatient care episodes, of which 3817 (46.8%), 1614 (47.1%), and 328 (49.4%) occurred in the postintervention period, respectively. Salbutamol use decreased from 27.1% to 4.7%, 29.5% to 3.0%, and 44.4% to 3.9% (P < .001) in PC centers, Eds, and hospital wards, respectively. In PC, corticosteroid and antibiotic prescribing rates fell from 10.1% to 1.7% and 13.7% to 5.1%, respectively (P < .001). In EDs and hospital wards, epinephrine use rates fell from 14.2% to 4.2% (P < .001) and 30.4% to 19.8% (P = .001), respectively. No variations were noted in balancing measures. CONCLUSIONS: The scaling up of the BICP was associated with significant decreases in the use of medications in managing bronchiolitis across a regional health service without unintended consequences.

Reducción de la tasa de incidencia de bronquiolitis aguda y de las hospitalizaciones asociadas a la enfermedad, durante la pandemia de COVID-19 / Reduction in the incidence of acute bronchiolitis and related hospital admissions during the COVID-19 pandemic

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Reducing Unnecessary Treatments for Acute Bronchiolitis Through an Integrated Care Pathway.

OBJECTIVES: To analyze the impact of an integrated care pathway on reducing unnecessary treatments for acute bronchiolitis. METHODS: We implemented an evidence-based integrated care pathway in primary care (PC) centers and the referral emergency department (ED). This is the third quality improvement cycle in the management of acute bronchiolitis implemented by our research team. Family and provider experiences were incorporated by using design thinking methodology. A multifaceted plan that included several quality improvement initiatives was adopted to reduce unnecessary treatments. The primary outcome was the percentage of infants prescribed salbutamol. Secondary outcomes were prescribing rates of other medications. The main control measures were hospitalization and unscheduled return rates. Salbutamol prescribing rate data were plotted on run charts. RESULTS: We included 1768 ED and 1092 PC visits, of which 913 (51.4%) ED visits and 558 (51.1%) PC visits occurred in the postintervention period. Salbutamol use decreased from 7.7% (interquartile range [IQR] 2.8-21.4) to 0% (IQR 0-1.9) in the ED and from 14.1% (IQR 5.8-21.6) to 5% (IQR 2.7-8) in PC centers. In the ED, the overall epinephrine use rate fell from 9% (95% confidence interval [CI], 7.2-11.1) to 4.6% (95% CI, 3.4-6.1) (P < .001). In PC centers, overall corticosteroid and antibiotic prescribing rates fell from 3.5% (95% CI, 2.2-5.4) to 1.1% (95% CI, 0.4-2.3) (P =.007) and from 9.5% (95% CI; 7.3-12.3) to 1.7% (95% CI, 0.9-7.3) (P <.001), respectively. No significant variations were noted in control measures. CONCLUSIONS: An integrated clinical pathway that incorporates the experiences of families and clinicians decreased the use of medications in the management of bronchiolitis.

Initiatives to reduce treatments in bronchiolitis in the emergency department and primary care.

We performed a quality improvement initiative to reduce unnecessary treatments for acute bronchiolitis (AB) in primary care (PC) and the referral paediatric emergency department (ED). The quality improvement initiative involved two seasons: 2016-2017 (preintervention) and 2017-2018 (postintervention). We distributed an evidence-based protocol, informative posters and badges with the slogan 'Bronchiolitis, less is more'. We also held interactive sessions, and paediatricians received weekly reports on bronchodilator prescription. The main outcome was the percentage of infants prescribed salbutamol. Secondary outcomes were epinephrine, antibiotic and corticosteroid prescription rates. Control measures were ED visit and hospitalisation rates, triage level, length of stay, intensive care admission and unscheduled returns with admission. We included 1878 ED and 1192 PC visits of which 855 (44.5%) and 534 (44.7%) occurred in the postintervention period, respectively. In the ED, salbutamol and epinephrine prescription rates fell from 13.8% (95% CI 11.8% to 16%) to 9.1% (95% CI 7.3% to 11.2%) (p<0.01) and 10.4% (95% CI 8.6% to 12.4%) to 9% (95% CI 7.2% to 11.1%) (n.s.), respectively. In PC, salbutamol, corticosteroid and antibiotic prescription rates fell from 38.3% (95% CI 34.6% to 42.0%) to 15.9% (95% CI 12.9% to 19.5%) (p<0.01), 12.9% (95% CI 10.5% to 15.7%) to 3.6% (95% CI 2.2% to 5.7%) (p<0.01) and 29.6% (95% CI 26.2% to 33.2%) to 9.5% (95% CI 7.2% to 12.5%) (p<0.01), respectively. No significant variations were noted in control measures. We safely decreased the use of unnecessary treatments for AB. Collaboration between PC and ED appears to be an important factor for success.