OBJECTIVES

A bronchiolitis integrated care pathway (BICP) proved useful in reducing the use of unnecessary medications at a local level. The aim of this study was to reduce overtreatment by scaling up the BICP across our regional health service in the 2019 and 2020 bronchiolitis season.

METHODS

We conducted a quality improvement (QI) initiative in 115 primary care (PC) centers and 7 hospitals in the Basque Country, Spain, from October 2019 to March 2020. The primary outcome measure was the percentage of children prescribed salbutamol comparing the rate to that in the previous bronchiolitis season (October 2018–March 2019). Secondary outcomes were the use of other medications. Balancing measures were hospitalization and unscheduled return rates.

RESULTS

We included 8153 PC visits, 3424 emergency department (ED) attendances, and 663 inpatient care episodes, of which 3817 (46.8%), 1614 (47.1%), and 328 (49.4%) occurred in the postintervention period, respectively. Salbutamol use decreased from 27.1% to 4.7%, 29.5% to 3.0%, and 44.4% to 3.9% (P < .001) in PC centers, Eds, and hospital wards, respectively. In PC, corticosteroid and antibiotic prescribing rates fell from 10.1% to 1.7% and 13.7% to 5.1%, respectively (P < .001). In EDs and hospital wards, epinephrine use rates fell from 14.2% to 4.2% (P < .001) and 30.4% to 19.8% (P = .001), respectively. No variations were noted in balancing measures.

CONCLUSIONS

The scaling up of the BICP was associated with significant decreases in the use of medications in managing bronchiolitis across a regional health service without unintended consequences.

About 10% of children have an episode of bronchiolitis in their first year of life, with this type of infection being the most frequent cause of hospitalization worldwide in this age group,1  and associated costs have increased over recent decades.2  In addition, bronchiolitis places a substantial burden on families and caregivers, with multiple visits to primary care (PC) centers and/or emergency departments (EDs).3 

Though current evidenced-based guidelines for the management of bronchiolitis emphasize the importance of high value care, with supportive measures and counseling for families, and discourage routine use of bronchodilators and other medications,4,5  unnecessary interventions are commonly carried out worldwide.69  In line with this, our research team identified an overtreatment problem, mainly the use of salbutamol, in our health service in the Basque Country, Spain, which provides almost universal comprehensive health care that is free at the point of delivery. As a result, we assessed local barriers to adopting evidence-based practice in the management of bronchiolitis. Then, we designed a plan of interventions that were developed across 3 consecutive improvement cycles in 2 health districts of our regional health service (RHS) between 2016 and 2019. The improvement cycles were associated with reductions in the use of pharmacotherapy in bronchiolitis in the EDs and PC centers.1012 

These successful improvement cycles were, however, carried out in a limited sample of PC centers in just 2 of the 13 districts of our RHS and its referral ED, which manage less than 20% of all infants diagnosed with bronchiolitis in our region. After demonstrating its local effectiveness, we proposed to our RHS Directorate to scale up the bronchiolitis integrated care pathway (BICP) to its entire set of 13 health districts.

Thus, the purpose of this study was to reduce overtreatment by scaling up the BICP across our regional health service in the 2019–2020 bronchiolitis season.

We conducted a quality improvement (QI) initiative, evaluating the effectiveness of a multicomponent strategy to scale up the BICP, a set of structured intervention actions aimed at improving the management of this disease in accordance with the evidence-based recommended clinical practice, to all primary and specialized pediatric services across an entire RHS in Spain (Osakidetza-Basque Health Service). Our RHS is organized around 13 health districts. It has a total of 135 PC centers with 362 pediatricians who care for approximately 300 000 children, of whom 51 000 (17%) are infants younger than 2 years of age. Further, it has 8 EDs in 4 tertiary acute-care teaching hospitals and 4 community hospitals. These EDs provide care to children younger than 14 years of age, handling a mean of 280 000 emergency visits/year.

All children with a diagnosis of bronchiolitis, defined as the first episode of respiratory distress with signs of lower respiratory tract infection in children younger than 2 years of age,13  were considered eligible to receive care for bronchiolitis as stated by the BICP, regardless of whether they had comorbidities (congenital heart or lung disease, genetic, neurologic or neuromuscular disorders, or immunodeficiency). Episodes of bronchiolitis in patients previously diagnosed with bronchiolitis ≥1 month ago were excluded because this new episode would no longer be considered bronchiolitis (by the previously mentioned definition).

The BICP scale-up initiative, promoting optimized use of pharmacotherapies and overall management of children with bronchiolitis, has been implemented in all PC centers, EDs, and inpatient facilities of the RHS. We should recall that 3 previous QI cycles were implemented in the 2016 to 2017, 2017 to 2018, and 2018 to 2019 bronchiolitis seasons in 2 districts of this RHS.1012  Although the BICP has now been implemented in all centers of the RHS, this study focuses on the results obtained following its deployment in the 115 PC centers and 7 EDs of the 11 districts not involved in the previous QI interventions on the management of bronchiolitis.

For this QI process, we formed a 25-person improvement team made up of emergency and PC pediatricians, pediatric residents, pediatric nurses, nurse aides, clinical epidemiologists, and specialists in health care quality and implementation science. Following a model of improvement (the Plan-Do-Study-Act cycle) and based on the experience gained through the application of improvement cycles in three successive bronchiolitis seasons from 2016 to 2019, the improvement team developed the BICP (Supplemental Fig 5).

The BICP is a structured plan detailing the key steps in the multidisciplinary management of an infant with bronchiolitis at different levels of care and promotes the coordinated practice of all agents involved as supported by the available evidence.12  One month before the start of the 2019 to 2020 bronchiolitis epidemic season, the BICP was further improved through a workshop using a focus group methodology.14  The workshop was held with district and hospital deployment teams composed of physicians and nurses involved in the management of bronchiolitis, selected by the research team based on their experience in pediatric PC, emergency and hospital medicine, and health care quality. At this workshop, the research team presented the results and conclusions of the BICP implementation in the baseline bronchiolitis season. Participants proposed improvements and made suggestions for incorporation into the BICP and were invited to discuss major potential barriers to implementing the BICP in their districts in general and their own workplaces in particular. The most important changes made to the BICP were unification of the triage process and initial nursing care in PC and ED settings; reorganization of the timetabling of appointments in PC centers during the bronchiolitis season, to give nurses and pediatricians more time to provide information and training to families; and preparation of training material on bronchiolitis for less experienced health professionals.

To spread and scale the BICP to all the PC and ED departments in the RHS and encourage its adoption by providers, we set up a multicomponent dissemination strategy, optimizing strategies previously shown to be effective and adding new agreed-on strategies. Briefly, the strategy includes: the identification and promotion of local key influencers with a targeted training component; a train-the-trainers component for health care professional training; educational tools and information materials for professionals and families; a computerized order entry set based on pathway content; fortnightly audit/feedback through e-mail to pediatricians comparing their own rate of bronchodilator use with that of their peers; and monthly multichannel (eg, e-mail, web-based) reminders about the characteristics of the BICP and related topics on evidence-based bronchiolitis care. A more detailed description of this action plan can be found in Supplemental Table 3 and the report of previous research carried out by our team.12  In addition to these strategies already in place, a health care organization-level campaign was launched to increase awareness of the RHS Directorate’s support of the BICP. Both the BICP and the multifaceted dissemination strategy were put into practice from the beginning of the 2019 to 2020 bronchiolitis season. Face-to-face training sessions for health professionals were conducted by local leaders in each district during the first month of the bronchiolitis season. All these strategies and interventions sought to activate and strengthen key drivers of BICP scale-up and adoption, these being system support, high-quality evidence, shared goals, provider commitment, and parent empowerment (Fig 1).

FIGURE 1

Diagram displaying the key drivers (center); that is, system factors affecting the project outcome listed in the aim (left) and the interventions that were employed to address each key driver (right).

FIGURE 1

Diagram displaying the key drivers (center); that is, system factors affecting the project outcome listed in the aim (left) and the interventions that were employed to address each key driver (right).

Close modal

The primary outcome measure was the percentage of clinical encounters with children diagnosed with bronchiolitis in which salbutamol was prescribed in PC centers or administered in EDs. Secondary outcomes evaluated were the percentages of infants with bronchiolitis receiving salbutamol in hospital wards, and antibiotics, corticosteroids, and epinephrine in EDs and hospital wards and prescribed antibiotics and corticosteroids in PC centers.

To explore any unintended consequences of reductions in the use of pharmacotherapy, we studied the following as balancing measures: the overall rate of hospital admission, the length of stay in the ED, and the rate of unscheduled returns within 72 hours (overall, cases, and resulting in admission).

The BICP points out that the diagnosis of bronchiolitis should only be used in children younger than 2 years of age and encourages the use of a score to assess the severity of each episode. For this reason, we used as process measures the percentages of children who were ≥2 years of age and episodes in which the severity score was documented out of the total number of children diagnosed with bronchiolitis.

A multidisciplinary evaluation committee (J.B., C.S., J.I.P., and A.S.) was responsible for abstracting, managing, and analyzing demographic, clinical, and medical prescribing data for all patients with International Classification of Diseases-9 or -10 codes related to bronchiolitis collected during annual bronchiolitis seasons: October to March 2018 to 2019 (baseline period) and October to March 2019 to 2020 (intervention period). Data on the primary outcome measure were pulled weekly from the health information system of the Basque Health Service through a computerized search tool developed ad hoc, whereas data on the secondary and process measures were retrieved at the end of each bronchiolitis season.

Quantitative data were expressed as means and SDs and categorical data as frequencies and percentages. Two study periods were established: the baseline or preintervention period (2018–2019 bronchiolitis season) and the postintervention period (2019–2020 bronchiolitis season). Run charts15  were used to display weekly outcome measures during the baseline and postintervention phases. On each run chart, the outcome of interest was plotted on the vertical axis against time on the horizontal axis. The median of the first phase was plotted as a reference baseline line to improve interpretation of the time series data in the 2 periods analyzed, more specifically by helping in the identification of potential trends and shifts. Additionally, the median of the second phase was also plotted when it became clear that both in PC and ED, there was a shift from the pre- to the postintervention periods to allow checking for stability or trends in postintervention data, following currently accepted rules.15  Interrupted time series analysis methods were used to provide supplementary accurate numerical estimates of the magnitude of intervention-induced shifts in use of salbutamol and display variation in reduction across the different health districts. Briefly, ordinary least squares regression models of the percentage of salbutamol use on time and study periods were fitted and residuals assessed for serial correlation, using the Cumby-Huizinga general test.16  For the ED data, a serial first-order correlation was identified, whereas for PC centers no significant serial correlation was detected. Linear least squares regression models with robust standard errors adjusted for observed autocorrelation were used following the method proposed by Newey-West. Weighted estimates of the absolute reduction in the percentage of salbutamol use were obtained, accounting for the number of bronchiolitis cases seen every 2 weeks. The models were also used to examine whether there was a linear time trend in the outcome at baseline and whether there was a significant change in time trend after the intervention. Stata 16.1 for Windows commands itsa and actest were used for the time series analyses and tests for serial correlation, respectively (StataCorp 2019, Stata Statistical Software: release 16; College Station, TX: StataCorp LLC).

The study was approved by the Ethics Committee of the Basque Country. The need for parental consent was waived because the children did not undergo any interventions related to this study and data were handled anonymously.

During the study period, 3424 episodes of bronchiolitis were recorded in the EDs (1810 at baseline and 1614 in the postintervention period) and 8153 in the PC centers participating in the initiative (4336 and 3817, respectively). Furthermore, a total of 663 hospital inpatients were diagnosed with bronchiolitis (335 at baseline and 328 in the postintervention period).

Salbutamol use decreased in PC centers and the EDs, with the mean percentage of patients receiving this drug falling, respectively, from 27.1% (95% confidence interval [CI], 25.7–28.4) to 4.7% (95% CI, 4.1–5.5) and from 29.5% (95% CI, 27.4–37.1) to 3.0% (95% CI, 2.3–4) (P < .001 in both cases) (Table 1). This reduction was also neatly shown by the run charts, which depicted clear downward shifts all over the postintervention period, relative to median values in the baseline period (Figs 2 and 3). The salbutamol prescribing rates in each of the districts and EDs in both bronchiolitis seasons are shown in Fig 4.

FIGURE 2

Run chart showing time (weekly) trends in use of salbutamol in bronchiolitis cases seen at primary care centers in 2 epidemic seasons, along with the median in each period. The vertical dashed line represents the time between waves, during which interventions took place. The number of bronchiolitis cases seen each week is given in parentheses on the x-axis.

FIGURE 2

Run chart showing time (weekly) trends in use of salbutamol in bronchiolitis cases seen at primary care centers in 2 epidemic seasons, along with the median in each period. The vertical dashed line represents the time between waves, during which interventions took place. The number of bronchiolitis cases seen each week is given in parentheses on the x-axis.

Close modal
FIGURE 3

Run chart showing time (weekly) trends in use of salbutamol in bronchiolitis cases seen at emergency departments in 2 epidemic seasons, along with the median in each period. The vertical dashed line represents the time between waves, during which interventions took place. The number of bronchiolitis cases seen each week is given in parentheses on the x-axis.

FIGURE 3

Run chart showing time (weekly) trends in use of salbutamol in bronchiolitis cases seen at emergency departments in 2 epidemic seasons, along with the median in each period. The vertical dashed line represents the time between waves, during which interventions took place. The number of bronchiolitis cases seen each week is given in parentheses on the x-axis.

Close modal
FIGURE 4

Salbutamol prescribing rates in each of (A) primary care health districts and the (B) emergency departments in both acute bronchiolitis seasons.

FIGURE 4

Salbutamol prescribing rates in each of (A) primary care health districts and the (B) emergency departments in both acute bronchiolitis seasons.

Close modal
TABLE 1

Comparison of the Rates of Medication Use in Episodes of Acute Bronchiolitis Seen in the Emergency Departments, Primary Care Centers, and Wards Where the Bronchiolitis Integrated Care Pathway Was Implemented Between the Pre- and Postintervention Bronchiolitis Seasons

Baseline, 2018–2019 SeasonPostintervention, 2019–2020 SeasonP
Primary care centers    
 All episodes, n 4336 3817  
 Salbutamol prescribed, n; % (95% CI) 1180; 27.2 (25.7–28.4) 177; 4.6 (4.1–5.5) <.001 
 Antibiotics prescribed, n; % (95% CI) 593; 13.6 (12.6–14.7) 194; 5.0 (4.4–5.8) <.001 
 Corticosteroids prescribed, n; % (95% CI) 454; 10.4 (9.5–11.4) 66; 1.7 (1.3–2.1) <.001 
Emergency departments    
 All episodes, n 1810 1614  
 Salbutamol administered, n; % (95% CI) 534; 29.5 (27.4–37.1) 49; 3.0 (2.3–4.0) <.001 
 Epinephrine administered, n; % (95% CI) 258; 14.2 (12.7–15.9) 69; 4.2 (3.4–5.4) <.001 
 Antibiotics administered, n; % (95% CI) 16; 0.8 (0.5–1.4) 9; 0.5 (0.2–1.0) .316 
 Corticosteroids administered, n; % (95% CI) 48; 2.6 (2.1–3.3) 10; 0.6 (0.3–1.1) <.001 
Hospital wards    
 All inpatients, n 335 328  
 Salbutamol administered, n; % (95% CI) 149; 44.4 (39.2–49.8) 13; 3.9 (2.3–6.6) <.001 
 Epinephrine administered, n; % (95% CI) 102; 30.4 (25.7–35.5) 65; 19.8 (15.8–24.4) .001 
 Antibiotics administered, n; % (95% CI) 33; 9.8 (7.1–13.5) 17; 5.1 (3.2–8.1) .027 
 Corticosteroids administered, n; % (95% CI) 18; 5.3 (3.4–8.3) 2; 0.6 (0.1–2.2) <.001 
Baseline, 2018–2019 SeasonPostintervention, 2019–2020 SeasonP
Primary care centers    
 All episodes, n 4336 3817  
 Salbutamol prescribed, n; % (95% CI) 1180; 27.2 (25.7–28.4) 177; 4.6 (4.1–5.5) <.001 
 Antibiotics prescribed, n; % (95% CI) 593; 13.6 (12.6–14.7) 194; 5.0 (4.4–5.8) <.001 
 Corticosteroids prescribed, n; % (95% CI) 454; 10.4 (9.5–11.4) 66; 1.7 (1.3–2.1) <.001 
Emergency departments    
 All episodes, n 1810 1614  
 Salbutamol administered, n; % (95% CI) 534; 29.5 (27.4–37.1) 49; 3.0 (2.3–4.0) <.001 
 Epinephrine administered, n; % (95% CI) 258; 14.2 (12.7–15.9) 69; 4.2 (3.4–5.4) <.001 
 Antibiotics administered, n; % (95% CI) 16; 0.8 (0.5–1.4) 9; 0.5 (0.2–1.0) .316 
 Corticosteroids administered, n; % (95% CI) 48; 2.6 (2.1–3.3) 10; 0.6 (0.3–1.1) <.001 
Hospital wards    
 All inpatients, n 335 328  
 Salbutamol administered, n; % (95% CI) 149; 44.4 (39.2–49.8) 13; 3.9 (2.3–6.6) <.001 
 Epinephrine administered, n; % (95% CI) 102; 30.4 (25.7–35.5) 65; 19.8 (15.8–24.4) .001 
 Antibiotics administered, n; % (95% CI) 33; 9.8 (7.1–13.5) 17; 5.1 (3.2–8.1) .027 
 Corticosteroids administered, n; % (95% CI) 18; 5.3 (3.4–8.3) 2; 0.6 (0.1–2.2) <.001 

Furthermore, the prescription of antibiotics and corticosteroids decreased significantly in PC centers, as did the use of epinephrine and corticosteroids in EDs. In hospital inpatients, there were also significant reductions in the percentages of infants receiving salbutamol, epinephrine, corticosteroids, and antibiotics (Table 1).

Overall absolute reduction in percentage use of salbutamol between the end of the first season and the beginning of the second was 17.8% for EDs (95% CI, 6.00–29.6) and 29.9% for PC centers (95% CI, 25.1–34.8) (Supplemental Tables 4 and 5). All 11 health districts of our RHS in which scaling-up activities were deployed showed a statistically significant drop in frequency of use of salbutamol (range, 5.2%–53.2% for EDs and 9.7%–65.2% for PC centers) between end of baseline and beginning of postintervention periods. No change in time trends of usage was apparent in the intervention season compared with baseline.

There were no significant changes in the overall rates of hospital admission or length of stay in the ED. Furthermore, the rates of revisits, both overall and those resulting in admission, were significantly lower after the interventions (Table 2).

TABLE 2

Balancing Measures for Episodes Seen in Emergency Departments in the 2 Bronchiolitis Seasons

Total Population of Patients Seen in Emergency Departments2018-2019 Season, n = 18102019-2020 Season, n = 1614P
Mean length of stay, min (SD) 160.5 (209.3) 157.0 (211.6) .551 
Hospitalization rate, n (%; 95% CI) 380 (21.0; 19.1–22.9) 322 (20.0; 18.1–22.0) .471 
All emergency department revisits, n (%; 95% CI) 363 (20.0; 18.2–21.9) 272 (16.9; 15.1–18.8) .017 
Revisits resulting in admission, n (%; 95% CI) 123 (6.7; 5.7–8.0) 79 (4.9; 3.9–6.0) .020 
Total Population of Patients Seen in Emergency Departments2018-2019 Season, n = 18102019-2020 Season, n = 1614P
Mean length of stay, min (SD) 160.5 (209.3) 157.0 (211.6) .551 
Hospitalization rate, n (%; 95% CI) 380 (21.0; 19.1–22.9) 322 (20.0; 18.1–22.0) .471 
All emergency department revisits, n (%; 95% CI) 363 (20.0; 18.2–21.9) 272 (16.9; 15.1–18.8) .017 
Revisits resulting in admission, n (%; 95% CI) 123 (6.7; 5.7–8.0) 79 (4.9; 3.9–6.0) .020 

The percentage of episodes for which severity score was documented increased from 37.1% (95% CI, 35.3–38.9) to 76.1% (95% CI, 74.3–77.8) and from 9.4% (95% CI, 8.6–10.2) to 69.1% (95% CI, 67.6–70.4) in the EDs and PC centers, respectively (P < .001 in both cases). The percentage of children diagnosed with bronchiolitis who were ≥2 years of age dropped from 1% (95% CI, 0.7–1.5) to 0.4% (95% CI, 0.2–0.8) and from 8.4% (95% CI, 7.7–9.3) to 2.6% (95% CI, 2.2–3.2) in the EDs and PC centers, respectively (P < .001in both cases).

We have successfully scaled up an integrated care pathway for bronchiolitis (our BICP) across all PC centers and hospitals of a whole RHS. This team-based initiative to deploy an improvement initiative has succeeded in reducing the use of medications in the treatment of bronchiolitis in primary care centers and hospitals without unintended consequences, such as increases in rates of hospital admission or return to the ED. The implementation of the BICP also produced an improvement in the overall management of bronchiolitis, represented by more appropriate diagnosing and better documenting of episode severity.

To our knowledge, this is the first improvement initiative on bronchiolitis applied to all levels of care across an RHS. Previous studies have demonstrated the benefits of QI measures implemented at the local level or with collaboration between different health care settings.1721  Nonetheless, improvement in managing bronchiolitis in a single hospital or group of health care facilities does not guarantee that the same will happen in their wider health care environment.22  This is illustrated by our observations in the 2018 to 2019 bronchiolitis season, in which we piloted the bronchiolitis care pathway in only 2 districts and 1 ED in our RHS, and medication use in the other districts and hospitals remained high, similar to patterns observed in previous seasons.12 

On the other hand, the overall decrease in the use of bronchodilators in our study is significant, greater than that shown in previous studies.2325  Care pathways have proven to be powerful tools for achieving change in clinical practice2631 ; however, it has been recognized that to spread a care pathway, it is essential to identify facilitating factors and barriers in the setting where it is to be applied.3234  In our case, we believe that 1 of the key factors lies in the use of a care pathway that includes the experience of families and health care professionals.12  In addition, the BICP incorporated suggestions and improvements proposed by the leaders of the different districts, aware of the specific characteristics of their geographical area. Another interesting feature of the BICP that may influence the use of medications is that it includes the recommendation not to use the diagnosis of bronchiolitis in children older than age 2 years. Although there is no consistency with regard to age (<12 months or <24 months), no guidelines or expert consensus consider the diagnosis of bronchiolitis in children older than 2 years of age.4,5  Because misclassification of bronchiolitis may lead to inappropriate management,35  the decrease in the number of children older than age 2 years diagnosed with bronchiolitis following the dissemination of the BICP may have contributed to the drop in the use of medications.

Another important aspect of our improvement initiative is the development of a strategy for the dissemination of the care pathway. An effective deployment system standardizes organizational work. Research analyzing differences between sites at which QI collaborative initiatives were successful and unsuccessful has identified the following as key factors: team engagement, including the setting up of multidisciplinary collaborative teams led by recognized site champions and the ability to leverage information technology resources and benchmarking activities, such as sharing data on medication prescribing between providers.36,37  We believe that our dissemination strategy contains many of these factors, in particular, the weekly comparative report of medication prescribing data from the different districts.

An important observation, however, is that, according to our results (Supplemental Tables 4 and 5), the magnitude of change in using medications linked to the scale-up initiative and its time pattern were not uniform across all the health districts. Furthermore, there seems to be a common changing pattern of drug administration within each season, with higher rates at the beginning and end of each epidemic wave. This is a very interesting, as-yet unexplained finding and can also be seen in the control charts of previous studies.11,12,2325  In our case, the observation of somewhat higher rates of salbutamol use in different districts and at different times of the bronchiolitis season seems to occur when there are smaller numbers of bronchiolitis episodes. There are likely other clinical as well as contextual and behavioral factors involved in this treatment pattern that warrant further research.

Another interesting finding in our study is the reduction in the rates of revisits, both overall and those resulting in admission, after the interventions. This could be explained by patients seen in the postintervention period being less severely ill, and a corresponding decrease in resource use. Nonetheless, there was no significant change in the percentage of patients admitted in our postintervention season, and hence, we consider it more plausible that educational materials provided to families increased their confidence in the management of bronchiolitis and therefore made them less likely to feel the need to take their child back to the ED.

The challenge for the future is to ensure that the significant improvement observed in the management of bronchiolitis is sustained over the coming seasons. We plan to make the BICP routine in the management of bronchiolitis. In relation to this, we believe that involving families and patients in the improvement initiative, as we are doing, is a key element in ensuring its success.12,38,39  In addition, we believe it is important to have an epidemiologic surveillance system with the goal of achieving early detection of respiratory syncytial virus circulation, to launch an information campaign in the traditional media and on social networks and to prepare the health organization and professionals for the upcoming bronchiolitis season.

We recognized that our study has certain limitations. First, it was conducted only in 1 RHS and, even if quality improvement is adequately disseminated, there may be contextual factors that influence its success. Factors such as the type of leadership, the motivation of the team, and the data infrastructure may lead to the same project not achieving the expected results elsewhere. Second, we did not include a control group, and it is therefore possible that our results were due to a trend in the management of bronchiolitis or to reasons other than the improvement initiatives undertaken. Third, we did not check whether the physicians used the McConnochie criteria for the diagnosis of bronchiolitis,14  as recommended in the care pathway, and therefore differences in the physicians' diagnostic criteria could have affected salbutamol utilization rates. Last, some districts saw very few cases of bronchiolitis over the entire epidemic seasons, which is likely to have blurred the effect of interventions to some extent and hindered estimation of the impact of the deployment strategy. Nonetheless, we believe these limitations are unlikely to have significantly affected the overall conclusions drawn.

In summary, this study shows a successful deployment of a bronchiolitis clinical pathway in PC centers and hospitals across the health service of an entire region. This multidisciplinary team-based initiative to deploy an integrated care pathway has led to a significant reduction in the use of medications in infants treated for bronchiolitis in PC centers, EDs, and inpatient care without unintended consequences such as increased rates of hospital admission or return to the ED. We believe that the stepped, adaptive development and characteristics of this complex intervention may make the improvement sustainable in future bronchiolitis seasons and supports its transferability to other health systems.

Dr Montejo conceptualized and designed the study, supervised data collection, analyzed the data, wrote and critically revised the initial draft of the manuscript, and approved the final manuscript as submitted. Dr Paniagua collaborated in the study design, wrote and critically revised the initial draft of the manuscript, and approved the final manuscript as submitted. Dr Pijoan analyzed the data, revised multiple versions of the manuscript, and decisively contributed to the latest version of the manuscript. Dr Saiz-Hernando collaborated in the design of the study, participated in data collection, critically revised the manuscript, and approved the final manuscript as submitted. Mrs Castelo collaborated in the design of the study, participated in data collection, revised multiple versions of the initial manuscript, and critically revised the final manuscript. Mrs Martin collaborated in the design of the study, participated in data collection, revised multiple versions of the initial manuscript, and critically revised the final manuscript. Mr Sanchez collaborated in the design of the study, participated in data collection, revised multiple versions of the initial manuscript, and critically revised the final manuscript. Dr Benito conceptualized and designed the study, supervised data collection, analyzed the data, wrote and critically revised the initial draft, and approved the final manuscript as submitted. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: ISCIII “PI19/00234,” cofunded by ERDF/ESF, “Investing in your future.”

CONFLICT OF INTEREST DISCLOSURES: The authors have no conflicts of interest relevant to this article to disclose.

BICP

Bronchiolitis Integrated Care Pathway

CI

confidence interval

ED

emergency department

PC

primary care

QI

quality improvement

RHS

regional health service

1
Meissner
HC
.
Viral bronchiolitis in children
.
N Engl J Med
.
2016
;
374
(
1
):
62
72
2
Pelletier
AJ
,
Mansbach
JM
,
Camargo
CA
Jr
.
Direct medical costs of bronchiolitis hospitalizations in the United States
.
Pediatrics
.
2006
;
118
(
6
):
2418
2423
3
Petruzella
FD
,
Gorelick
MH
.
Duration of illness in infants with bronchiolitis evaluated in the emergency department
.
Pediatrics
.
2010
;
126
(
2
):
285
290
4
American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis
.
Diagnosis and management of bronchiolitis
.
Pediatrics
.
2006
;
118
(
4
):
1774
1793
5
Ralston
SL
,
Lieberthal
AS
,
Meissner
HC
, et al;
American Academy of Pediatrics
.
Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis
.
Pediatrics
.
2014
;
134
(
5
):
e1474
e1502
6
Schuh
S
,
Babl
FE
,
Dalziel
SR
, et al;
Pediatric Emergency Research Networks (PERN)
.
Practice variation in acute bronchiolitis: a Pediatric Emergency Research Networks Study
.
Pediatrics
.
2017
;
140
(
6
):
e20170842
7
Parikh
K
,
Hall
M
,
Teach
SJ
.
Bronchiolitis management before and after the AAP guidelines
.
Pediatrics
.
2014
;
133
(
1
):
e1
e7
8
Parikh
K
,
Hall
M
,
Mittal
V
, et al
.
Establishing benchmarks for the hospitalized care of children with asthma, bronchiolitis, and pneumonia
.
Pediatrics
.
2014
;
134
(
3
):
555
562
9
Florin
TA
,
Byczkowski
T
,
Ruddy
RM
,
Zorc
JJ
,
Test
M
,
Shah
SS
.
Variation in the management of infants hospitalized for bronchiolitis persists after the 2006 American Academy of Pediatrics bronchiolitis guidelines
.
J Pediatr
.
2014
;
165
(
4
):
786
92.e1
10
Montejo Fernández
M
,
Benito Manrique
I
,
Montiel Eguía
A
,
Benito Fernández
J
.
[An initiative to reduce the use of unnecessary medication in infants with bronchiolitis in primary care]
.
An Pediatr (Engl Ed)
.
2019
;
90
(
1
):
19
25
11
Montejo
M
,
Paniagua
N
,
Saiz-Hernando
C
,
Martinez-Indart
L
,
Mintegi
S
,
Benito
J
.
Initiatives to reduce treatments in bronchiolitis in the emergency department and primary care
.
Arch Dis Child
.
2021
;
106
(
3
):
294
300
12
Montejo
M
,
Paniagua
N
,
Saiz-Hernando
C
,
Martinez-Indart
L
,
Castelo
S
,
Martin
V
,
Benito
J
.
Reducing unnecessary treatments for acute bronchiolitis trough an integrated care pathway
.
Pediatrics
.
2021
;
147
(
6
):
e20194021
13
McConnochie
KM
.
Bronchiolitis. What’s in the name?
Am J Dis Child
.
1983
;
137
(
1
):
11
13
14
Powell
RA
,
Single
HM
.
Focus groups
.
Int J Qual Health Care
.
1996
;
8
(
5
):
499
504
15
Perla
RJ
,
Provost
LP
,
Murray
SK
.
The run chart: a simple analytical tool for learning from variation in healthcare processes
.
BMJ Qual Saf
.
2011
;
20
(
1
):
46
51
16
Cumby
RE
,
Huizinga
J
.
Testing the autocorrelation structure of disturbances in ordinary least squares and instrumental variables regressions
.
Econometrica
.
1992
;
60
(
1
):
185
195
17
Ralston
S
,
Comick
A
,
Nichols
E
,
Parker
D
,
Lanter
P
.
Effectiveness of quality improvement in hospitalization for bronchiolitis: a systematic review
.
Pediatrics
.
2014
;
134
(
3
):
571
581
18
Schondelmeyer
AC
,
Simmons
JM
,
Statile
AM
, et al
.
Using quality improvement to reduce continuous pulse oximetry use in children with wheezing
.
Pediatrics
.
2015
;
135
(
4
):
e1044
e1051
19
Ralston
S
,
Parikh
K
,
Goodman
D
.
Benchmarking overuse of medical interventions for bronchiolitis
.
JAMA Pediatr
.
2015
;
169
(
9
):
805
806
20
Kotagal
UR
,
Robbins
JM
,
Kini
NM
,
Schoettker
PJ
,
Atherton
HD
,
Kirschbaum
MS
.
Impact of a bronchiolitis guideline: a multisite demonstration project
.
Chest
.
2002
;
121
(
6
):
1789
1797
21
Murch
H
,
Oakley
J
,
Pierrepoint
M
,
Powell
C
.
Using multifaceted education to improve management in acute viral bronchiolitis
.
Arch Dis Child
.
2015
;
100
(
7
):
654
658
22
Ralston
SL
,
Atwood
EC
,
Garber
MD
,
Holmes
AV
.
What works to reduce unnecessary care for bronchiolitis? A qualitative analysis of a national collaborative
.
Acad Pediatr
.
2017
;
17
(
2
):
198
204
23
Ralston
SL
,
Garber
MD
,
Rice-Conboy
E
, et al;
Value in Inpatient Pediatrics Network Quality Collaborative for Improving Hospital Compliance with AAP Bronchiolitis Guideline (BQIP)
.
A multicenter collaborative to reduce unnecessary care in inpatient bronchiolitis
.
Pediatrics
.
2016
;
137
(
1
)
24
Mussman
GM
,
Lossius
M
,
Wasif
F
, et al
.
Multisite emergency department inpatient collaborative to reduce unnecessary bronchiolitis care
.
Pediatrics
.
2018
;
141
(
2
):
e20170830
25
Tyler
A
,
Krack
P
,
Bakel
LA
, et al
.
Interventions to reduce over-utilized tests and treatments in bronchiolitis
.
Pediatrics
.
2018
;
141
(
6
):
e20170485
26
Indig
D
,
Lee
K
,
Grunseit
A
,
Milat
A
,
Bauman
A
.
Pathways for scaling up public health interventions
.
BMC Public Health
.
2017
;
18
(
1
):
68
27
Lion
KC
,
Wright
DR
,
Spencer
S
,
Zhou
C
,
Del Beccaro
M
,
Mangione-Smith
R
.
Standardized clinical pathways for hospitalized children and outcomes
.
Pediatrics
.
2016
;
137
(
4
):
e20151202
28
Browne
GJ
,
Giles
H
,
McCaskill
ME
,
Fasher
BJ
,
Lam
LT
.
The benefits of using clinical pathways for managing acute paediatric illness in an emergency department
.
J Qual Clin Pract
.
2001
;
21
(
3
):
50
55
29
Panella
M
,
Marchisio
S
,
Di Stanislao
F
.
Reducing clinical variations with clinical pathways: do pathways work?
Int J Qual Health Care
.
2003
;
15
(
6
):
509
521
30
Kurtin
P
,
Stucky
E
.
Standardize to excellence: improving the quality and safety of care with clinical pathways
.
Pediatr Clin North Am
.
2009
;
56
(
4
):
893
904
31
Jabbour
M
,
Curran
J
,
Scott
SD
, et al
.
Best strategies to implement clinical pathways in an emergency department setting: study protocol for a cluster randomized controlled trial
.
Implement Sci
.
2013
;
8
:
55
32
Evans-Lacko
S
,
Jarrett
M
,
McCrone
P
,
Thornicroft
G
.
Facilitators and barriers to implementing clinical care pathways
.
BMC Health Serv Res
.
2010
;
10
:
182
33
Bulthuis
SE
,
Kok
MC
,
Raven
J
,
Dieleman
MA
.
Factors influencing the scale-up of public health interventions in low- and middle-income countries: a qualitative systematic literature review
.
Health Policy Plan
.
2020
;
35
(
2
):
219
234
34
Milat
AJ
,
Bauman
A
,
Redman
S
.
Narrative review of models and success factors for scaling up public health interventions
.
Implement Sci
.
2015
;
10
:
113
35
Megalaa
R
,
Perez
GF
,
Kilaikode-Cheruveettara
S
,
Kotwal
N
,
Rodriguez-Martinez
CE
,
Nino
G
.
Clinical definition of respiratory viral infections in young children and potential bronchiolitis misclassification
.
J Investig Med
.
2018
;
66
(
1
):
46
51
36
Currie
G
,
Spyridonidis
D
.
Sharing leadership for diffusion of innovation in professionalized settings
.
Hum Relat
.
2019
;
72
(
7
):
1209
1233
37
Greenhalgh
T
,
Papoutsi
C
.
Spreading and scaling up innovation and improvement
.
BMJ
.
2019
;
365
:
l2068
38
Trebble
TM
,
Hansi
N
,
Hydes
T
,
Smith
MA
,
Baker
M
.
Process mapping the patient journey: an introduction
.
BMJ
.
2010
;
341
:
c4078
39
Meyer
MA
.
Mapping the patient journey across the continuum: lessons learned from one patient’s experience
.
J Patient Exp
.
2019
;
6
(
2
):
103
107

Supplementary data