How Low Can You Go: What Is the Goal for Bronchiolitis Quality Improvement? Free

In this issue of Hospital Pediatrics, Lawrence et al present a 3-year quality improvement initiative at a large Australian children’s hospital that achieved a >50% reduction in albuterol use for bronchiolitis.¹  Impressive, and even more impressive is that the final use rate was 3.2%; only 3% of children with bronchiolitis got albuterol in the emergency department. This result is so much lower than anything reported in the United States that it bears further discussion. Although I do not want to take away from the investigators’ achievement, part of this impressive performance on a longstanding overuse issue in pediatrics is the tighter definition of bronchiolitis used in Australia (and in much of Europe as well). Whereas studies in the United States consistently include patients up to the age of 24 months, Europe and Australia more consistently limit the diagnostic term to children <12 months of age.

The impact of the narrower age criteria comes into sharper focus when we examine responses from individuals in the study who overrode the electronic medical record best practice alert and prescribed albuterol anyway. “Almost 12 months of age” was the most common reason cited in nearly one-half of the alert overrides. Both the low rate of use and the main reason for the rare deviations from the pathway suggest that age may be a more important driver of albuterol use in bronchiolitis than we have so far acknowledged in the United States.

The argument used by those who have advocated for the broader age criteria for bronchiolitis is reasonably evidence-based. In the most recent meta-analysis of therapies, 54 of 150 trials include children up to 24 months of age, and a substantial proportion of the remainder include children up to 18 months of age; thus, older children are well-represented in studies.²  Nevertheless, older children have significantly larger airways, and it is logical to believe that wheezing at 23 months of age is different from wheezing at 3 months of age, if only from the standpoint of the amount of pathology required to narrow airways of such differing size. The absence of good tools to evaluate infant lower respiratory tract disease at the bedside further limits our ability to make sense of the clinical trial data. Most studies rely on respiratory scores, which are proxy outcomes, and few scores have even been evaluated on their ability to predict real clinical outcomes.^3–5  Generally, researchers have contented themselves with a focus on interrater reliability and have often failed to consider other key psychometric properties, such as floor and ceiling effects, in respiratory score development.⁵  Nevertheless, scores possess so much face validity with clinicians that it is uncommon to see them questioned, despite the absence of strong evidence to support the current usage.

There have been international working groups assembled to create a consensus definition of bronchiolitis, and there have even been calls to do away with the term altogether.^6,7  Naturally, we want a diagnostic term to correlate with a clear treatment plan, and we do not like uncertainty. In the case of bronchiolitis, all roads seem to lead to a deep and abiding need to know when we should use a bronchodilator. In the absence of a truly accurate way to distinguish bronchodilator responsiveness at the bedside (e.g., a score that holds up to systematic scrutiny), the authors of the current study would argue that the narrower definition of bronchiolitis may do the most good to reduce unnecessary therapies. The large majority of hospitalizations for bronchiolitis occur in the <12-month age group, and thus if we had clarity that this is the group to prioritize for albuterol avoidance, we might do the most good for the most patients. However, a counterargument to such logic is that we are generally terrible at thinking about treatment effects at the population level, particularly when confronted with a patient immediately in front of us in apparent respiratory distress. Such logic suggests that many people will continue to use medications regardless because the current patient “might benefit,” and that obligation will override all others.

That this dilemma is truly pressing to clinicians is borne out in another study in this issue of the journal. Zurca, et al have performed an international survey of 657 intensive care physicians around the question of testing and intervention in critically ill patients with bronchiolitis.⁸  They note that the majority of patients are reported to receive nonevidence-based interventions for bronchiolitis in the ICU and that clinicians report that guidelines addressing intensive care for bronchiolitis would be helpful. Unfortunately, best practices for guidelines dictate that high-quality evidence (generally randomized controlled trials) is necessary to formulate treatment recommendations, and there are few randomized trials performed in this specific population. Rescue care, in general, is an area in which the imperative to use any therapy because “it might help” is strong, and it would take multiple randomized controlled trials to change that culture around a single test or intervention in bronchiolitis ICU care. A decades-long push to create high-quality evidence involving multiple sites would be necessary. Until then, we are left with the messy uncertainty that plagues so much of medicine.

Despite the uncertainty, the bulk of the literature probably supports at least 1 key point: most of what we have to offer for bronchiolitis does not alter the course of the disease. Some of what we do could make some patients feel better, or possibly, we are programmed to interpret a random sequence of events as an improvement. Infrequently, patients need truly life-sustaining interventions like intubation and mechanical ventilation, but we cannot predict who will need these things well until they are close to needing them. If we narrow the definition of the disease, some older children will receive unnecessary diagnoses or medications which will not benefit them and could cause harm. On the other hand, if we do not throw the kitchen sink at a patient and they end up intubated, we will suffer from the belief that we might have averted that outcome. The absence of evidence is not evidence of absence, as so many are so fond of saying when they feel the psychological pressure to act. It is an understatement to characterize the current state of affairs as unsatisfactory.

Yet, we do the best we can when the patient in front of us needs our help because, at its most basic, that is our job. Our best is far from perfect, and uncertainty is impossible to avoid in bronchiolitis, as in nearly all medicine. Evidence-based medicine is, in my opinion, clearly better than the other alternatives; however, the idea that we will soon have an evidence-based diagnostic and therapeutic pathway to fit every patient is extremely unlikely. Practically, what that means is that we will never get to 0 on nonevidence-based care in bronchiolitis, nor should we.