Effectiveness of Quality Improvement in Hospitalization for Bronchiolitis: A Systematic Review

BACKGROUND: Bronchiolitis causes nearly 20% of all acute care hospitalizations for young children in the United States. Unnecessary testing and medication for infants with bronchiolitis contribute to cost without improving outcomes. OBJECTIVES: The goal of this study was to systematically review the quality improvement (QI) literature on inpatient bronchiolitis and to propose benchmarks for reducing unnecessary care. METHODS: Assisted by a medical librarian, we searched Medline, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library. Studies describing any active QI intervention versus usual care in hospitalized children,2 years of age were included. Data were extracted and confirmed by multiple investigators and pooled by using a random effects model. Benchmarks were calculated by using achievable benchmarks of care methods. RESULTS: Fourteen studies involving >12 000 infants were reviewed. QI interventions resulted in 16 fewer patients exposed to repeated doses of bronchodilators per 100 hospitalized (7 studies) (risk difference: 0.16 [95% confidence interval: 0.11-0.21]) and resulted in 5.3 fewer doses of bronchodilator given per patient (95% confidence interval: 2.1-8.4). Interventions resulted in fewer hospitalized children exposed to steroids (5 per 100), chest radiography (9 per 100), and antibiotics (4 per 100). No significant harms were reported. Benchmarks derived from the reported data are: repeated bronchodilator use, 16%; steroid use, 1%; chest radiography use, 42%; and antibiotic use, 17%. The study's heterogeneity limited the ability to classify specific characteristics of effective QI interventions. CONCLUSIONS: QI strategies have been demonstrated to achieve lower rates of unnecessary care in children hospitalized with viral bronchiolitis than are the norm.