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Randomized Controlled Trial
. 2021 Aug 1;175(8):797-806.
doi: 10.1001/jamapediatrics.2021.0295.

Effectiveness of Targeted Interventions on Treatment of Infants With Bronchiolitis: A Randomized Clinical Trial

Libby Haskell  1 , Emma J Tavender  2   3 , Catherine L Wilson  2 , Sharon O'Brien  4   5 , Franz E Babl  2   6   7 , Meredith L Borland  4   8 , Elizabeth Cotterell  9   10 , Rachel Schembri  11 , Francesca Orsini  11 , Nicolette Sheridan  12 , David W Johnson  13 , Ed Oakley  2   7   14 , Stuart R Dalziel  1   15 ; PREDICT Network
Affiliations
Randomized Controlled Trial

Effectiveness of Targeted Interventions on Treatment of Infants With Bronchiolitis: A Randomized Clinical Trial

Libby Haskell et al. JAMA Pediatr. .

Abstract

Importance: In developed countries, bronchiolitis is the most common reason for infants to be admitted to the hospital, and all international bronchiolitis guidelines recommend supportive care; however, significant variation in practice continues with infants receiving non-evidence-based therapies. Deimplementation research aims to reduce the use of low-value care, and advancing science in this area is critical to delivering evidence-based care.

Objective: To determine the effectiveness of targeted interventions vs passive dissemination of an evidence-based bronchiolitis guideline in improving treatment of infants with bronchiolitis.

Design, setting, and participants: This international, multicenter cluster randomized clinical trial included 26 hospitals (clusters) in Australia and New Zealand providing tertiary or secondary pediatric care (13 randomized to intervention, 13 to control) during the 2017 bronchiolitis season. Data were collected on 8003 infants for the 3 bronchiolitis seasons (2014-2016) before the implementation period and 3727 infants for the implementation period (2017 bronchiolitis season, May 1-November 30). Data were analyzed from November 16, 2018, to December 9, 2020.

Interventions: Interventions were developed using theories of behavior change to target key factors that influence bronchiolitis management. These interventions included site-based clinical leads, stakeholder meetings, a train-the-trainer workshop, targeted educational delivery, other educational and promotional materials, and audit and feedback.

Main outcomes and measures: The primary outcome was compliance during the first 24 hours of care with no use of chest radiography, albuterol, glucocorticoids, antibiotics, and epinephrine, measured retrospectively from medical records of randomly selected infants with bronchiolitis who presented to the hospital. There were no patient-level exclusions.

Results: A total of 26 hospitals were randomized without dropouts. Analysis was by intention to treat. Baseline data collected on 8003 infants for 3 bronchiolitis seasons (2014-2016) before the implementation period were similar between intervention and control hospitals. Implementation period data were collected on 3727 infants, including 2328 boys (62%) and 1399 girls (38%), with a mean (SD) age of 6.0 (3.2) months. A total of 459 (12%) were Māori (New Zealand), and 295 (8%) were Aboriginal/Torres Strait Islander (Australia). Compliance with recommendations was 85.1% (95% CI, 82.6%-89.7%) in intervention hospitals vs 73.0% (95% CI, 65.3%-78.8%) in control hospitals (adjusted risk difference, 14.1%; 95% CI, 6.5%-21.7%; P < .001).

Conclusions and relevance: Targeted interventions led to improved treatment of infants with bronchiolitis. This study has important implications for bronchiolitis management and the development of effective interventions to deimplement low-value care.

Trial registration: Australian and New Zealand Clinical Trials Registry: ACTRN12616001567415.

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Conflict of interest statement

Conflict of Interest Disclosures: Ms Haskell reported receiving grants from the Health Research Council of New Zealand (19/140) during the conduct of the study. Dr Tavender reported receiving grants from the National Health and Medical Research Council during the conduct of the study. Ms Wilson reported receiving grants (no. 1058560) from the National Health and Medical Research Council, Australia, and nonfinancial support from the Victorian Government's Operational Infrastructure Support Program, Australia, during the conduct of the study. Ms Orsini reported receiving grants (no. 1058560) from the National Medical Research Council, Australia, and from the Victorian Government's Operational Infrastructure Support Program, Australia, during the conduct of the study. Dr Oakley reported receiving grants from the National Health and Medical Research Council, Australia, during the conduct of the study. Dr Dalziel reported receiving grants from the Health Research Council of New Zealand, grants from the National Medical Research Council, Australia, grants from the Cure Kids New Zealand Research support, and grants from the Starship Foundation during the conduct of the study. No other disclosures were reported.

Figures

Figure.
Figure.. Consolidated Standards of Reporting Trials (CONSORT) Flow Diagram and Study Design
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