Hindawi BioMed Research International Volume 2017, Article ID 9730696, 6 pages https://doi.org/10.1155/2017/9730696
Research Article Predictors of Inappropriate Use of Diagnostic Tests and Management of Bronchiolitis Lorena Sarmiento,1 Gladys E. Rojas-Soto,2 and Carlos E. Rodríguez-Martínez3,4 1
Department of Pediatrics, Clinica Universitaria Colombia, Fundacion Universitaria Sanitas, Bogota, Colombia Department of Pediatric Respiratory Medicine, Hospital El Pino, University of Santiago de Chile (USACH), Santiago, Chile 3 Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia 4 Department of Pediatric Pulmonology and Pediatric Critical Care Medicine, School of Medicine, Universidad El Bosque, Bogota, Colombia 2
Correspondence should be addressed to Carlos E. Rodr´ıguez-Mart´ınez;
[email protected] Received 19 February 2017; Accepted 28 May 2017; Published 3 July 2017 Academic Editor: Luis Martinez-Sobrido Copyright © 2017 Lorena Sarmiento et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. The aim of the present study was to determine predictors of inappropriate use of diagnostic tests and management of bronchiolitis in a population of hospitalized infants. Methods. In an analytical cross-sectional study, we determined independent predictors of the inappropriate use of diagnostic tests and management of bronchiolitis in a population of hospitalized infants. We defined a composite outcome score as the main outcome variable. Results. Of the 303 included patients, 216 (71.3%) experienced an inappropriate use of diagnostic tests and treatment of bronchiolitis. After controlling for potential confounders, it was found that atopic dermatitis (OR 5.30; CI 95% 1.14–24.79; 𝑝 = 0.034), length of hospital stay (OR 1.48; CI 95% 1.08–2.03; 𝑝 = 0.015), and the number of siblings (OR 1.92; CI 95% 1.13–3.26; 𝑝 = 0.015) were independent predictors of an inappropriate use of diagnostic tests and treatment of the disease. Conclusions. Inappropriate use of diagnostic tests and treatment of bronchiolitis was a highly prevalent outcome in our population of study. Participants with atopic dermatitis, a longer hospital stay, and a greater number of siblings were at increased risk for inappropriate use of diagnostic tests and management of the disease.
1. Introduction Acute bronchiolitis represents the most important cause of lower respiratory tract infection during the first year of life and is the leading reason for hospitalization of infants beyond the neonatal period [1]. The disease is usually associated with substantial direct and indirect costs, not only for healthcare systems but also for families and society as a whole [2]. Although bronchiolitis is an extremely common disease and several clinical practice guidelines (CPGs) of acceptable quality have been developed [3], there is still a significant use and overuse of medications with insufficient evidence of effectiveness [4] and use of unnecessary diagnostic tests [5], generating unnecessary and costly resource use with no improvement in important clinical outcomes [6]. It is important to identify predictors of inappropriate use of diagnostic tests and management of bronchiolitis, which
would help to plan more focused strategies and more targeted efforts in hope of achieving better disease management. An implementation strategy of CPGs that deal with the identified predictors could help to reduce the inappropriate use and overuse of diagnostic tests and medications that lack strong evidence that supports a recommendation for their routine use [4]. This implementation strategy could lead to the economical and effective use of health care services and the avoidance of wasting resources without reducing the quality of these services, finally contributing to the improvement of disease outcomes. To date, only a few studies have identified predictors of inappropriate use of diagnostic tests and management of bronchiolitis, showing that the region or the community where the patients were treated [7, 8] and whether patients were treated in a non-universityaffiliated hospital were independent predictors of inappropriate management of bronchiolitis [7]. However, there is a need
2 for further studies, which ideally should account for patientrelated variables such as disease severity and the presence of comorbidities and atopic conditions, not only in patients but also in their families. Accordingly, the aim of the present study was to identify potential factors associated with the inappropriate use of diagnostic tests and management of bronchiolitis in a population of infants hospitalized for acute viral bronchiolitis in the Fundaci´on Hospital La Misericordia, a university-affiliated hospital located in the metropolitan area of Bogota, Colombia.
2. Material and Methods 2.1. Bronchiolitis Clinical Practice Guideline (CPG). At the time of the study’s inception, an evidence-based bronchiolitis institutional CPG was available at the Fundaci´on Hospital La Misericordia and served as a basis for guidance about which diagnostic tests and medications should be used in infants treated in the hospital for any acute viral bronchiolitis episode [9]. The bronchiolitis CPG recommends against routine use of diagnostic tests such as a hemogram, C-reactive protein, and procalcitonin and suggests that C-reactive protein and procalcitonin should be ordered only for infants with suspected serious bacterial infections. Likewise, the CPG recommends against the routine use of chest X-rays, suggesting that they should be ordered only for infants with diagnostic uncertainty, severe disease, or an atypical disease course. With respect to pharmacologic therapy, the CPG also recommends against the routine use of inhaled bronchodilators (beta 2 agonists, anticholinergics), nebulized epinephrine, and anti-inflammatories (inhaled or systemic corticosteroids) but allows for the option of a monitored trial of inhaled bronchodilators or nebulized epinephrine, continuing their administration only if there is a documented positive clinical response to the trial using an objective means of evaluation. Finally, the CPG also recommends that nebulized hypertonic saline be administered to infants hospitalized for bronchiolitis in order to shorten hospital stay but recommends against its use in the emergency department. 2.2. Study Design and Procedures. An analytical crosssectional study was performed during the period from March to June 2014, in a random sample of patients aged 3 was designated as “inappropriate use of diagnostic tests and treatment of bronchiolitis.” The sole use of anticholinergics (nebulized or inhaled) or corticosteroids (inhaled or systemic) was deemed to be an “inappropriate use of diagnostic tests and treatment of bronchiolitis,” independent of the composite outcome score. A sensitivity analysis was performed using a range of cutoff values from 1 to 5 of the composite outcome score for defining “inappropriate use of diagnostic tests and treatment of bronchiolitis.” 2.4. Statistical Analysis. Continuous variables are presented as mean ± standard deviation (SD) or median (interquartile range [IQR]), whichever is appropriate. Categorical variables are presented as numbers (percentage). Differences between continuous variables were analyzed using the unpaired 𝑡-test or Wilcoxon’s signed rank test, whichever was appropriate. Associations between categorical variables and the outcome variable were analyzed using the chi-square test or Fisher’s exact test, whichever was appropriate. To identify factors independently associated with an inappropriate use of diagnostic tests and treatment of bronchiolitis, we used logistic regression models, adjusting for potential confounding variables. The predictive variables included in the models were the age of the patients, the number of days with respiratory symptoms, a parental history of asthma, and the presence of at least one underlying disease or condition associated with severe disease. All statistical tests were two-tailed, and the
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Table 1: Demographic characteristics and clinical information of the patients included in the study, according to the appropriateness of bronchiolitis diagnosis and treatment. Variable Age (months; median (interquartile range–IQR)) Gender, M/F Presence of breastfeeding for at least six months Nursery attendance Number of siblings Number of days with respiratory symptoms Less than 24 hours Between 24 and 72 hours More than 72 hours Presence of underlying disease conditions Previous use of oxygen therapy Personal history or diagnosis of atopic dermatitis Parental history of asthma Respiratory syncytial virus isolation Length of hospital stay Need for home oxygen administration Need for pediatric intensive care unit Need for endotracheal intubation Mortality ∗
Patients with inadequate diagnosis and treatment∗ (𝑛 = 216)
Patients with adequate diagnosis and treatment (𝑛 = 87)
𝑝 value
3.0 (1.0–7.0) 131/85 31 (14.4%) 20 (9.3%) 1.0 (0.0–1.0)
3.0 (1.0–6.0) 45/42 14 (16.1%) 7 (8.0%) 0.0 (0.0–1.0)
0.966 0.154 0.665 0.780 0.306
19 (8.8%) 192 (88.8%) 3 (1.4%) 26 (12.0%) 6.0 (6.9%) 7.0 (8.0%) 32 (14.8%) 95 (44.0%) 4.0 (3.0–6.0) 76 (35.2%) 4 (1.9%) 1 (0.5%) 0 (0.0%)
12 (13.8%) 71 (81.6%) 1 (1.1%) 13 (14.9%) 5.0 (2.3%) 6.0 (2.8%) 13 (14.9%) 20 (23.0%) 3.0 (2.0–4.0) 22 (25.3%) 0 (0.0%) 0 (0.0%) 0 (0.0%)
0.211 0.095 1.00 0.513 0.055 0.073 0.846
