MP32: Using physician practice reports and feedback sessions to reduce low value care in bronchiolitis

Background: Despite strong evidence recommending supportive care as the mainstay of management for most infants with bronchiolitis, prior studies suggest that many of these patients receive low-value interventions. Providing clinicians with their practice reports and peer comparator data or an achievable benchmark of care (audit and feedback) has been shown to be an effective strategy to improve adherence to guidelines. Aim Statement: To decrease low-value care (use of any or all of chest radiographs, viral testing and salbutamol) in infants with bronchiolitis by delivering individual physician reports in addition to Group Facilitated Feedback Sessions (GFFS) to pediatric emergency physicians (PEPs). Measures & Design: Our cohort included 3,883 patients ≤12 months old that presented to two emergency departments with a diagnosis of bronchiolitis from April 1, 2013 to April 30, 2018. Using administrative data we captured baseline characteristics and interventions. Consenting PEPs received two audit and feedback (A&F) reports which included their individual and peer comparator data. Two multi-disciplinary GFFS (including inpatient pediatricians, nurse, learners and respiratory therapists) 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 analyzed using statistical process control charts. Process measures (consent to obtain report, attendance and evaluations from the feedback session) and balancing measures were also captured. Evaluation/Results: 78% of PEPs consented to receive their A&F reports. Patient baseline characteristics were similar in the baseline (n = 3109) and intervention period (n = 774). Following the baseline physician reports and the GFFS, low-value care decreased from 42.6% to 27.1% (absolute difference: -15.5%; 95% confidence interval (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 ICU admission (absolute difference: -0.6%; 95%CI: -5.7% to 4.4%) and ED revisit within 72 hours (absolute difference: -0.1%; 95% CI: -3.1% to 3.0% non-admitted patients, 1.0%; 95% CI: -1.2% to 3.2% admitted patients) were unchanged. Discussion/Impact: The combination of audit and feedback and a GFFS significantly reduced low-value care for pediatric patients with bronchiolitis by PEP's.

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Reducing Unnecessary Respiratory Viral Testing to Promote High-Value Care

PEDIATRICS ◽

10.1542/peds.2020-042366 ◽

2022 ◽

Author(s):

Olivia Ostrow ◽

Deena Savlov ◽

Susan E. Richardson ◽

Jeremy N. Friedman

Keyword(s):

Control Charts ◽

Respiratory Infections ◽

Audit And Feedback ◽

Improvement Strategy ◽

Statistical Process ◽

Process Control Charts ◽

Statistical Process Control Charts ◽

Viral Testing ◽

Return Visits ◽

Viral Respiratory Infections

BACKGROUND AND OBJECTIVES: Viral respiratory infections are common in children, and practice guidelines do not recommend routine testing for typical viral illnesses. Despite results often not impacting care, nasopharyngeal swabs for viral testing are frequently performed and are an uncomfortable procedure. The aim of this initiative was to decrease unnecessary respiratory viral testing (RVT) in the emergency department (ED) and the pediatric medicine wards (PMWs) by 50% and 25%, respectively, over 36 months. METHODS: An expert panel reviewed published guidelines and appropriate evidence to formulate an RVT pathway using plan-do-study-act cycles. A multifaceted improvement strategy was developed that included implementing 2 newer, more effective tests when testing was deemed necessary; electronic order modifications with force functions; audit and feedback; and education. By using statistical process control charts, the outcomes analyzed were the percentage of RVT ordered in the ED and the rate of RVT ordered on the PMWs. Balancing measures included return visits leading to admission and inpatient viral nosocomial outbreaks. RESULTS: The RVT rate decreased from a mean of 3.0% to 0.5% of ED visits and from 44.3 to 30.1 per 1000 patient days on the PMWs and was sustained throughout the study. Even when accounting for the new rapid influenza test available in the ED, a 50% decrease in overall ED RVT was still achieved without any significant impact on return visits leading to admission or inpatient nosocomial infections. CONCLUSIONS: Through implementation of a standardized, electronically integrated RVT pathway, a decrease in unnecessary RVT was successfully achieved. Audit and feedback, reminders, and biannual education all supported long-term sustainability of this initiative.

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

CJEM ◽

10.1017/cem.2020.374 ◽

2020 ◽

Vol 22 (5) ◽

pp. 678-686

Author(s):

Shawn K. Dowling ◽

Inelda Gjata ◽

Nathan M. Solbak ◽

Colin G.W. Weaver ◽

Katharine Smart ◽

...

Keyword(s):

Emergency Department ◽

Control Charts ◽

Patient Characteristics ◽

Pediatric Emergency ◽

Therapeutic Interventions ◽

Audit And Feedback ◽

Absolute Difference ◽

Emergency Physicians ◽

Feedback Session ◽

Statistical Process

ABSTRACTObjectiveDespite 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.MethodsOur 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.ResultsSeventy-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.ConclusionThe combination of audit and feedback and a group-facilitated feedback session reduced low-value care for patients with bronchiolitis.

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