Low-value Care, and Variation in Practice for Children Hospitalized With Bronchiolitis
- Conditions
- Bronchiolitis
- Interventions
- Diagnostic Test: Provision of any of six different low-value health services for treatment of bronchiolitis
- Registration Number
- NCT06506474
- Lead Sponsor
- St. Justine's Hospital
- Brief Summary
Low-value care is defined as the use of a health service, such as diagnostics and treatments, for which the harms or costs outweigh the benefits. In pediatrics, investigations or treatments can be unpleasant or traumatizing to the child, can prolong the time spent in hospital, and can create a cascade of further futile investigations and treatments. Several of the commonly used diagnostics and treatments in bronchiolitis are considered low-value, making it a great model to study low-value care in pediatrics.
The purpose of CareBEST is to study the use of 6 low-value healthcare services in children aged 1 to 12 months hospitalized with bronchiolitis, their costs, and measure the variability in practice of these services.
The main questions this study aims to answer are:
1. How frequently are 6 low-value care health services used in children hospitalized with bronchiolitis? These 6 low-value care health services are: 1) respiratory virus testing; 2) chest x-rays; 3) continuous pulse oximetry; 4) short-acting beta-agonists; 5) systemic corticosteroids; and 6) antibiotics.
* Are there factors that predict the use of these services?
* What are the costs of the use of these services?
2. How much variability is there between different patients, different doctors, and between hospitals in the use of these 6 low-value health services ?
3. Are differences in use of low-value health services associated with patient and family characteristics (like race and ethnicity, socioeconomic status, language), and do these contribute to disparities in care?
Participants will have their infant's medical chart reviewed during their hospitalization. They will also have 2 short questionnaires to complete, once during their child's admission to the hospital, and one 30 days later to ask about whether their child required any additional medical care. They will additionally be asked to complete a questionnaire on their perceptions regarding their child's care while hospitalized, including the use of shared-decision making and their understanding of and involvement in the care decisions made.
This analysis will provide a better understanding of treatment of bronchiolitis in Canada and help in the development of effective interventions to reduce low-value care.
- Detailed Description
Background: Low-value care is defined as the use of a health service, such as diagnostics and treatments, for which the harms or costs outweigh the benefits. Reducing low-value care is important in improving the health of Canadians and achieving a sustainable, high-quality healthcare system. Bronchiolitis is among the most common and most costly causes of hospitalizations in children. Most healthcare costs associated with bronchiolitis are related to hospitalization, and these costs have been increasing. Supportive care is recommended by national guidelines for the treatment of bronchiolitis, and many commonly used diagnostics and treatments in bronchiolitis are considered low-value, making it a great model to study low-value care in pediatrics. To develop effective interventions to reduce low-value care, and ensure the right resources go to the right patient at the right time, it is crucial to develop a better understanding of inpatient management of bronchiolitis in Canada.
The goal of this prospective multi-site observational study is to analyze the use of 6 low-value healthcare services in children diagnosed with bronchiolitis, their costs, and measure the variability in practice of these services.
Specific objectives: Among infants admitted with bronchiolitis at 15 Canadian hospitals with pediatric admissions, to:
1. Measure the incidence, patterns, and predictors of use of 6 low-value care health services and their costs in children hospitalized for bronchiolitis, namely 1) respiratory virus testing; 2) chest x-rays; 3) continuous pulse oximetry; 4) short-acting beta-agonists; 5) systemic corticosteroids; and 6) antibiotics;
2. Estimate the extent of practice variation in the use of 6 low-value health services between hospitals;
3. Determine whether differences in use of low-value health services are associated with patient and family characteristics (e.g., race and ethnicity, socioeconomic status, language), and whether these contribute to disparities in care.
Design: A multi-centre (n=15), prospective observational cohort study of children hospitalized with bronchiolitis. Data will be obtained from medical charts and entered into a central, web-based REDCap database. A health equity questionnaire will be completed by participants once during their child's admission and then again 30 days later to inquire on additional medical care required post-admission. Secondary outcomes and covariates will also be collected which include but are not limited to duration of ICU stay, use of mechanical ventilation, cardiac arrest, length of hospital stay, disease severity, clinician years of experience, and death.
Analysis of the primary outcome will be descriptive for each low-value health service, overall and stratified by sex. Costs of hospitalization will be assessed from a healthcare institution perspective. Cost of each of low-value health service will be described and compared between one another and across sites to identify key differences which may be targets for process change.
This study will provide important data to understand the use of low-value care in bronchiolitis treatment in Canada, and will inform our approach to addressing low-value care in bronchiolitis and in other common conditions.
Recruitment & Eligibility
- Status
- RECRUITING
- Sex
- All
- Target Recruitment
- 3000
- Children aged >28 days to <12 months
- Children admitted to a pediatric inpatient ward with an admission diagnosis of bronchiolitis
- Children previously recruited for the study, either during a previous bronchiolitis admission or for the same incident of bronchiolitis, while admitted to another study site.
Study & Design
- Study Type
- OBSERVATIONAL
- Study Design
- Not specified
- Arm && Interventions
Group Intervention Description Children Admitted to Hôpital Maisonneuve-Rosemont Provision of any of six different low-value health services for treatment of bronchiolitis Children aged \>28 days to \<12 months with an admission diagnosis of bronchiolitis, admitted to a general pediatric inpatient unit, not previously recruited for the study. Children admitted to Montreal Children's Hospital Provision of any of six different low-value health services for treatment of bronchiolitis Children aged \>28 days to \<12 months with an admission diagnosis of bronchiolitis, admitted to a general pediatric inpatient unit, not previously recruited for the study. Children admitted to IWK Children's Hospital Provision of any of six different low-value health services for treatment of bronchiolitis Children aged \>28 days to \<12 months with an admission diagnosis of bronchiolitis, admitted to a general pediatric inpatient unit, not previously recruited for the study. Children admitted to CHU Sainte-Justine Provision of any of six different low-value health services for treatment of bronchiolitis Children aged \>28 days to \<12 months with an admission diagnosis of bronchiolitis, admitted to a general pediatric inpatient unit, not previously recruited for the study. Children admitted to McMaster Children's Hospital Provision of any of six different low-value health services for treatment of bronchiolitis Children aged \>28 days to \<12 months with an admission diagnosis of bronchiolitis, admitted to a general pediatric inpatient unit, not previously recruited for the study. Children admitted to Children's Hospital of Western Ontario Provision of any of six different low-value health services for treatment of bronchiolitis Children aged \>28 days to \<12 months with an admission diagnosis of bronchiolitis, admitted to a general pediatric inpatient unit, not previously recruited for the study. Children admitted to Hôpital St-Jérôme Provision of any of six different low-value health services for treatment of bronchiolitis Children aged \>28 days to \<12 months with an admission diagnosis of bronchiolitis, admitted to a general pediatric inpatient unit, not previously recruited for the study. Children admitted to British Columbia Children's Hospital Provision of any of six different low-value health services for treatment of bronchiolitis Children aged \>28 days to \<12 months with an admission diagnosis of bronchiolitis, admitted to a general pediatric inpatient unit, not previously recruited for the study. Children admitted to CHU de Quebec University Laval Hospital Provision of any of six different low-value health services for treatment of bronchiolitis Children aged \>28 days to \<12 months with an admission diagnosis of bronchiolitis, admitted to a general pediatric inpatient unit, not previously recruited for the study. Children admitted to Hôpital Saint-Eustache Provision of any of six different low-value health services for treatment of bronchiolitis Children aged \>28 days to \<12 months with an admission diagnosis of bronchiolitis, admitted to a general pediatric inpatient unit, not previously recruited for the study. Children Admitted to Trillium Health Partners Provision of any of six different low-value health services for treatment of bronchiolitis Children aged \>28 days to \<12 months with an admission diagnosis of bronchiolitis, admitted to a general pediatric inpatient unit, not previously recruited for the study. Children admitted to Lakeridge Health Provision of any of six different low-value health services for treatment of bronchiolitis Children aged \>28 days to \<12 months with an admission diagnosis of bronchiolitis, admitted to a general pediatric inpatient unit, not previously recruited for the study. Children admitted to Children's Hospital of Eastern Ontario Provision of any of six different low-value health services for treatment of bronchiolitis Children aged \>28 days to \<12 months with an admission diagnosis of bronchiolitis, admitted to a general pediatric inpatient unit, not previously recruited for the study. Children admitted to The Hospital for Sick Kids Provision of any of six different low-value health services for treatment of bronchiolitis Children aged \>28 days to \<12 months with an admission diagnosis of bronchiolitis, admitted to a general pediatric inpatient unit, not previously recruited for the study. Children admitted to Cité-de-la-Santé Provision of any of six different low-value health services for treatment of bronchiolitis Children aged \>28 days to \<12 months with an admission diagnosis of bronchiolitis, admitted to a general pediatric inpatient unit, not previously recruited for the study. Children admitted to Kingston Health Sciences Centre Provision of any of six different low-value health services for treatment of bronchiolitis Children aged \>28 days to \<12 months with an admission diagnosis of bronchiolitis, admitted to a general pediatric inpatient unit, not previously recruited for the study. Children admitted to Alberta Children's Hospital Provision of any of six different low-value health services for treatment of bronchiolitis Children aged \>28 days to \<12 months with an admission diagnosis of bronchiolitis, admitted to a general pediatric inpatient unit, not previously recruited for the study. Children admitted to Stollery Children's Hospital Provision of any of six different low-value health services for treatment of bronchiolitis Children aged \>28 days to \<12 months with an admission diagnosis of bronchiolitis, admitted to a general pediatric inpatient unit, not previously recruited for the study.
- Primary Outcome Measures
Name Time Method The proportion of eligible patients receiving each of the six low-value health services 24 months The primary outcome of the study is the proportion of patients receiving each of the six low-value health services during their hospitalization for bronchiolitis: 1) respiratory virus testing; 2) chest x-ray; 3) continuous pulse oximetry; 4) short-acting beta-agonists; 5) systemic corticosteroids; and 6) antibiotics.
- Secondary Outcome Measures
Name Time Method Transfer to the ICU 24 months Whether the child admitted with bronchiolitis was transferred to the ICU. If so, duration of ICU stay.
Chest X-ray results 24 months Results of chest X-rays ordered. Obtained from medical record.
Use of inhaled corticosteroids 24 months Whether inhaled corticosteroids were administered during admission. Obtained from medical record.
Complete blood count 24 months Results of complete blood count. Obtained from medical record. Numerical
Use of Heated humidified high-flow nasal cannula (HHHFNC) 24 months Heated humidified high-flow nasal cannula (HHHFNC) help reduce work of breathing and can be beneficial in severe bronchiolitis cases. We will measure proportion of HHHFNC use in hospitalized children with bronchiolitis stratified by disease severity. Obtained from medical record.
Use of CPAP, BiPAP, or mechanical ventilation during admission. 24 months Use of continuous positive airway pressure (CPAP) or biphasic positive airway pressure (BiPAP), mechanical ventilation during admission, as documented in patient's admission record.
Use of low-flow supplemental oxygen 24 months Any use of low-flow supplemental oxygen, and duration of use.
Use of chest physiotherapy 24 months Whether chest physiotherapy was performed during admission. Obtained from medical record.
Antiviral prescription 24 months Any prescription for an antiviral effective against influenza during admission.Obtained from medical record.
Length of stay 24 months Length of hospital stay in hours, both in the ED and inpatient unit, measured using recorded time of arrival and departure to and from the ED and inpatient unit.
Cardiac arrest 24 months Whether the child experienced a cardiac arrest during their admission.
Nil per os order 24 months Any order for "nil per os" (feeding not permitted) during admission.
Venous blood gas 24 months Results of blood tests ordered; venous blood gas. Obtained from medical record. Numerical
Death 24 months Whether the child died during their admission.
Fluid supplementation 24 months Presence and type (intravenous vs. nasogastric) of fluid supplementation
Prescription at discharge from hospital 24 months Data collection on prescription at discharge from the hospital including the following: 1) repeat chest x-ray; 2) prescription for short-acting beta-agonists (SABA); 3) inhaled corticosteroids; 4) systemic corticosteroids; 5) antibiotics; and 6) antivirals.
Care received in the 30 days following discharge. 24 months Care received in the 30 days following the patient's discharge from the hospital, including outpatient follow-up appointments in the following 30 days, follow-up chest x-rays, as well as prescription for antibiotics, short-acting beta-agonists, and inhaled corticosteroids.
Return visits 24 months Using administrative data and parent surveys, we will measure return visits to the Emergency Department, and hospitalizations within 30 days following the initial bronchiolitis admission, overall and for respiratory illness.
Presence of bacterial co-infection 24 months Presence and type of bacterial co-infections. Obtained from medical record.
Electrolyte levels 24 months Electrolyte levels in blood. Obtained from medical record. Numerical
Cost of hospitalization 24 months Cost of hospitalization will be evaluated from a healthcare institution perspective with data from hospital decision support. More detailed costs data (micro-costing) will also be obtained whenever possible, allowing differentiation between services not readily discerned by traditional case costing methods typically based on resource intensity weights.
Trial Locations
- Locations (15)
Alberta Children's Hospital
🇨🇦Calgary, Alberta, Canada
Stollery Children's Hospital
🇨🇦Edmonton, Alberta, Canada
British Columbia Children's Hospital
🇨🇦Vancouver, British Columbia, Canada
IWK Health
🇨🇦Halifax, Nova Scotia, Canada
McMaster Children's Hospital
🇨🇦Hamilton, Ontario, Canada
Kingston Health Science Centre
🇨🇦Kingston, Ontario, Canada
Children's Hospital of Western Ontario (London Health Science Centre)
🇨🇦London, Ontario, Canada
Lakeridge Health
🇨🇦Oshawa, Ontario, Canada
Children's Hospital of Eastern Ontario
🇨🇦Ottawa, Ontario, Canada
Hospital for Sick Children
🇨🇦Toronto, Ontario, Canada
Centre hospitalier Cité-de-la-Santé
🇨🇦Laval, Quebec, Canada
Montreal Children's Hospital
🇨🇦Montréal, Quebec, Canada
Hôpital Maisonneuve-Rosemont
🇨🇦Montréal, Quebec, Canada
CHU Sainte-Justine
🇨🇦Montréal, Quebec, Canada
Centre Hospitalier Université Laval - Centre Mère-Enfant Soleil
🇨🇦Québec, Quebec, Canada