Sustainability in the AAP Bronchiolitis Quality Improvement Project

Analysis

Changes among baseline-, intervention-, and sustainability-season data were assessed using generalized linear mixed-effects models with random effect for study sites. Negative binomial models were used for count variables to allow for overdispersion. Length of stay was log-transformed to achieve a normal distribution. We also analyzed each site individually to assess whether sustained improvements were the result of broad sustainability across all sites or whether they represented an aggregation of some sites that continued to improve while other sites actually worsened.

To address any bias introduced by the voluntary and incomplete participation of sites in the sustainability season, we planned a priori to conduct 3 additional analyses. First, we compared the characteristics of sites that did participate in the sustainability season with those that did not participate by using Chi-squared tests for differences in proportions and t tests for differences in means. Second, we determined whether the baseline-season process and outcome measures were different between sites that did and did not participate using descriptive statistics. Third, we assessed whether improvements between the baseline and intervention seasons were different between sites that did and did not participate using a linear mixed-effects model for normally distributed outcomes and generalized linear mixed-effects model with site-specific random effects for nonnormally distributed outcomes. All study outcomes were summarized in terms of model-adjusted means along with the corresponding 95% confidence intervals. All P values are 2-sided, and P < 0.05 was used to define statistical significance. Data analyses were conducted using SAS software (SAS Institute Inc., Cary, North Carolina) version 9.4.

RESULTS

A total of 2275 patient encounters were reviewed, comprising 995 encounters from the baseline season, 877 from the intervention season, and 403 from the sustainability season. Improvements were observed across key bronchiolitis quality measures from the baseline to intervention season,⁹ although not every site improved in every metric. All improvements achieved by the combined groups during the intervention season were sustained during the sustainability season (Table 1). No measures demonstrated statistically significant reductions between the intervention and sustainability seasons, and the use of intermittent pulse oximetry continued to increase. Length of stay and 72-hour readmissions were not statistically different between seasons (P = 0.54 and P = 0.98, respectively).

Mean use of a respiratory score, which was 6.6% (95% confidence interval [CI], 1.8-21.5) in the baseline season, increased to 73.9% (95% CI, 56.9-85.9) during the intervention season and 70.7% (95 % CI, 53.8-83.5) in the sustainability season. The number of bronchodilator doses per encounter decreased from 3.1 (95% CI, 2.1-4.4) in the baseline season to 1.0 (95% CI, 0.7-1.4) in the intervention season and 0.8 (95% CI, 0.5-1.3) in the sustainability season. Orders for intermittent pulse oximetry increased significantly from a baseline of 40.6% (95% CI, 22.8-61.1) to 68.6% (95% CI, 47.4-84.1) in the intervention season and 79.2% (95% CI, 58.0-91.3) in the sustainability season. In general, this same pattern was present, ie, individual sites did not demonstrate significant improvement or worsening across the measures (Appendix 1a). The Figure illustrates individual site and overall project performance over the study period using bronchodilator use as a representative example.

Characteristics of sites that did and did not participate in the sustainability season were not significantly different (Table 2). The majority of sites were medium-sized centers that cared for an average of 100 to 300 inpatient cases of bronchiolitis per year and were located in an urban environment.

Differences in baseline bronchiolitis quality measures between sites that did and did not participate in the sustainability season are displayed in Table 3. Sustainability sites had significantly lower baseline use of a respiratory score, both to assess severity of illness at any point after hospitalization as well as to assess responsiveness following bronchodilator treatments (P < 0.001). At baseline they also had fewer orders for intermittent pulse oximetry use (P = 0.01) and fewer doses of bronchodilators per encounter (P = 0.04). Sites were not significantly different in their baseline use of bronchodilators, oral steroid doses, or chest radiographs. Sites that participated in the sustainability season demonstated larger magnitude improvement between baseline and intervention seasons for respiratory score use (P < 0.001 for any use and P = 0.02 to assess bronchodilator responsiveness; Appendix 1b).

DISCUSSION

To our knowledge, this is the first report of sustained improvements in care achieved through a multiinstitutional QI collaborative of community and academic hospitals focused on bronchiolitis care. We found that overall sites participating in a national bronchiolitis QI project sustained improvements in key bronchiolitis quality measures for 1 year following the project’s completion. For the aggregate group no measures worsened, and one measure, orders for intermittent pulse oximetry monitoring, continued to increase during the sustainability season. Furthermore, the sustained improvements were primarily the result of consistent sustained performance of each individual site, as opposed to averages wherein some sites worsened while others improved (Appendix 1a). These findings suggest that designing a collaborative approach, which provides an evidence-based best-practice toolkit while building the QI capacity of local interdisciplinary teams, can support performance gains that persist beyond the project’s active phase.