Sustainability of the de-implementation of low-value care in infants with bronchiolitis: 2-year follow-up of a cluster randomised controlled trial

Clinical Snapshot

Key Findings

• P Value: Not reported for sustainability outcome

• Effect Size: 80.9% adherence at 2 years (adjusted predicted adherence 80.8%)

• Primary Outcome: Sustained adherence to avoiding five low-value bronchiolitis practices at 2 years post-intervention

• Nnt Or Sensitivity: Risk difference from original intervention: -3.9% (95% CI: -8.6% to 0.8%), meeting pre-specified sustainability threshold of <7% decrease

• Confidence Interval: 95% CI: 77.4% to 84.2%

Clinical Application

Highly feasible - interventions target existing clinical practices and require minimal additional resources for sustained implementation Directly applicable to Australian practice with study conducted in Australian hospitals. Aligns with RACGP and paediatric society guidelines recommending supportive care for bronchiolitis. May inform PBS policy discussions regarding bronchodilator restrictions Infants presenting to emergency departments and paediatric wards with bronchiolitis in tertiary and secondary hospitals

Abstract

BACKGROUND: In 2017, the PREDICT (Paediatric Research in Emergency Departments International Collaborative) network conducted a cluster randomised controlled trial (cRCT) at 26 Australian and New Zealand hospitals to improve bronchiolitis care. Findings demonstrated that targeted interventions significantly improved adherence with five evidence-based low-value bronchiolitis practices (no chest radiography, salbutamol, glucocorticoids, antibiotics and epinephrine) in the first 24 hours of hospitalisation (adjusted risk difference, 14.1%; 95% CI: 6.5% to 21.7%; p<0.001). During the intervention year (2017), intervention hospital (n=13) compliance was 85.1% (95% CI: 82.6% to 89.7%). This study aimed to determine if improvements in bronchiolitis management were sustained at intervention hospitals 2 years post-trial completion. METHODS: International, multicentre follow-up study of hospitals in Australia and New Zealand that participated in a cRCT of de-implementation of low-value bronchiolitis practices, 1 year (2018) and 2 years (2019) post-trial completion, obtained retrospectively from medical audits. Sustainability was defined a priori as no more than a <7% decrease to any level of improvement in adherence for all five low-value practices (composite outcome) from the cRCT intervention year. RESULTS: Of the 26 hospitals, 11 intervention and 10 control hospitals agreed to participate in the follow-up study. Data were collected on 3299 infants with bronchiolitis 1 year (intervention and control hospitals) and 1689 infants 2 years post-trial (intervention hospitals). Adherence with no use of the five low-value practices 2 years post-trial completion was 80.9% (adjusted predicted adherence, 80.8%, 95% CI: 77.4% to 84.2%; estimated risk difference from cRCT outcome -3.9%, 95% CI: -8.6% to 0.8%) at intervention hospitals, fulfilling the a priori definition of sustainability. DISCUSSION: Targeted interventions, delivered over one bronchiolitis season, resulted in sustained improvements in bronchiolitis management in infants 2 years later. This follow-up study provides evidence for sustainability in de-implementing low-value care in bronchiolitis management. TRIAL REGISTRATION DETAILS: Australian and New Zealand Clinical Trials Registry No: ACTRN12621001287820.

References

1. 1.Ramsden, V., Babl, F. E., Haskell, L., Wilson, C., Middleton, S., Schembri, R., King, A., Wallace, A., Partyka, A., Baldock, C., Wong, J., Steinmann, K., Mills, L., Phillips, N., Poulter, N., Jani, S., Kenny, S., Oakley, E., Lithgow, A., Wilson, P., McInnes, E., Dalziel, S., & Tavender, E. (2026). Sustainability of the de-implementation of low-value care in infants with bronchiolitis: 2-year follow-up of a cluster randomised controlled trial. BMJ Quality & Safety. https://doi.org/10.1136/bmjqs-2024-018135