Reducing unwarranted chest x-rays in bronchiolitis: Importance of a robust analysis

Joanna Lawrence; Harriet Hiscock; Alice Voskoboynik; Ramesh Walpola; Anurag Sharma

doi:10.1111/jpc.16539

Reducing unwarranted chest x-rays in bronchiolitis: Importance of a robust analysis

J Paediatr Child Health. 2024 Apr 10. doi: 10.1111/jpc.16539. Online ahead of print.

Authors

Joanna Lawrence^{1

2

3

4}, Harriet Hiscock^{2

3}, Alice Voskoboynik⁵, Ramesh Walpola⁴, Anurag Sharma⁴

Affiliations

¹ Hospital in the Home, Royal Children's Hospital, Melbourne, Victoria, Australia.
² Health Services Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.
³ Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.
⁴ School of Population Health, Faculty of Medicine UNSW, Sydney, New South Wales, Australia.
⁵ Centre for Health Analytics, Melbourne Children's Campus, Melbourne, Victoria, Australia.

PMID: 38597355
DOI: 10.1111/jpc.16539

Abstract

Aim: Bronchiolitis is the commonest reason for hospitalisation amongst infants and is often a target for low-value care (LVC) reduction. We aimed to assess the impact of a multifaceted intervention (clinician education, parent engagement, audit-feedback) on rates of chest x-rays (CXR) in bronchiolitis.

Methods: Longitudinal study of CXRs ordered in infants (1-12 months) diagnosed with bronchiolitis in the Emergency Department (ED) of an Australian paediatric hospital between May 2016 and February 2023. We used logistic regression to measure the impact of the intervention on unwarranted CXR orders, controlling for other potential impacting variables such as time, patient characteristics (age/sex), clinical variables (fever, hypoxia, tachypnoea), seasonal factors (month, day of the week, business hours) and time passed since intervention.

Results: Ten thousand one hundred and nine infants were diagnosed with bronchiolitis in the ED over the study period, with 939 (9.3%) receiving a CXR, of which 69% (n = 651) were considered unwarranted. Rates of unwarranted CXRs reduced from 7.9% to 5.4% post-intervention (P < 0.0001). Logistic regression showed the intervention had no significant effect (OR 0.89, 95% CI 0.65-1.23) once other variables and underlying time-based trends were accounted for.

Conclusions: Although pre-post rates appeared significantly improved, a robust analysis demonstrated that our multi-faceted intervention was not effective in reducing CXRs in bronchiolitis. The decision to order CXR was associated with clinical features that overlap with pneumonia suggesting ongoing misconceptions regarding the role of CXR for this indication. Our study highlights the value of large electronic medical record datasets and robust methodology to avoid falsely attributing underlying trends to the LVC intervention.

Keywords: bronchioliits; low value care.

© 2024 The Authors. Journal of Paediatrics and Child Health published by John Wiley & Sons Australia, Ltd on behalf of Paediatrics and Child Health Division (The Royal Australasian College of Physicians).