Impact of the Choosing Wisely® Campaign Recommendations for Hospitalized Children on Clinical Practice: Trends from 2008 to 2017
BACKGROUND: The Choosing Wisely® Campaign (CWC) was launched in 2012. Five recommendations to reduce the use of “low-value” services in hospitalized children were published in 2013.
OBJECTIVES: The aim of this study was to estimate the frequency and trends of utilization of these services in tertiary children’s hospitals five years before and after the publication of the recommendations.
METHODS: We conducted a retrospective, longitudinal analysis of hospitalizations to 36 children’s hospitals from 2008 to 2017. The “low-value” services included (1) chest radiograph (CXR) for asthma, (2) CXR for bronchiolitis, (3) relievers for bronchiolitis, (4) systemic steroids for lower respiratory tract infection (LRTI), and (5) acid suppressor therapy for uncomplicated gastroesophageal reflux (GER). We estimated the annual percentages of the use of these services after risk adjustment, followed by an interrupted time series (ITS) analysis to compare trends before and after the publication of the recommendations.
RESULTS: The absolute decreases in utilization were 36.6% in relievers and 31.5% in CXR for bronchiolitis, 24.1% in acid suppressors for GER, 20.8% in CXR for asthma, and 2.9% in steroids for LRTI. Trend analysis showed that one “low-value” service declined significantly immediately (use of CXR for asthma), and another decreased significantly over time (relievers for bronchiolitis) after the CWC.
CONCLUSIONS: There was some decrease in the utilization of “low-value” services from 2008 to 2017. Limited changes in trends occurred after the publication of the recommendations. These findings suggest a limited impact of the CWC on clinical practice in these areas. Additional interventions are required for a more effective dissemination of the CWC recommendations for hospitalized children.
© 2019 Society of Hospital Medicine
RESULTS
Table 2 presents the demographic characteristics of the cohorts before (2008-2012) and after (2013-2017) the publication of the CWC-PHM recommendations. Hospitalizations due to asthma represented the largest cohort with 142,067 cases, followed by hospitalizations due to bronchiolitis with 94,253 cases. Hospitalizations due to GER comprised the smallest cohort with 13,635 cases. Most of the children had government insurance and had “minor” severity according to the All Patient Revised Diagnosis Related Group (APR-DRG) system.
We found statistically significant differences in most of the demographic characteristics for the cohorts when comparing cases before and after the introduction of the CWC-PHM recommendations.
After adjusting for demographic characteristics, we estimated the percentages of the utilization of the “low-value” services from 2008 to 2017. We observed a steady decrease in overutilization of all services over time. The absolute percentage decrease was more evident in the reduction of the utilization of relievers by 36.6% and that of CXR by 31.5% for bronchiolitis. We also observed a 20.8% absolute reduction in the use of CXR for asthma.
The use of systemic steroids in LRTI revealed the lowest utilization among the “low-value” services studied, with 15.1% in 2008 and 12.2% in 2017, a 2.9% absolute reduction. However, the prescription of acid suppressors for GER showed the highest utilization among all the overuse metrics studied, ie, 63% in 2008 and 48.9% in 2017, with an absolute decrease of 24.1%. The yearly adjusted estimated percentages of utilization for each “low-value” service are presented in Appendix Table A.
Table 3 and the Figure (attached as supplemental online graphic) respectively present the risk-adjusted ITS parameter estimates and the graphic representation before and after the inception of the CWC-PHM recommendations for the trend analysis.
During the five years preceding the intervention (2008-2012), a statistically significant decrease (P < .01) was already noted in the trend of utilization of relievers and CXR in bronchiolitis and CXR in asthma. However, we found no significant change in the trend of the use of systemic corticosteroids in cases with LRTI or the use of acid suppression therapy for GER.
The immediate effect of the intervention is represented by the level change. We found a statistically significant (P < .01) reduction according to the CWC-PHM recommendations only for the use of CXR in hospitalized children with uncomplicated asthma.
During the five years after the CWC-PHM recommendations were published (2013-2017), a sustained, significant decrease in the trend of the use of CXR in asthma and bronchiolitis and the use of relievers in bronchiolitis (P < .01) was observed. However, there was no significant change in the trend of the use of systemic corticosteroids in cases with LRTI or in the use of acid suppression therapy for GER during this period.
Comparison of the trends before and after the publication of the CWC-PHM recommendations revealed that only the decreasing trend in the use of relievers for bronchiolitis over time significantly correlated with the campaign (P < .01).
DISCUSSION
We found a steady reduction in the frequency of overutilization of five “low-value” services described in the CWC-PHM recommendations from 2008 to 2017 in 36 tertiary children’s hospitals in the US. This trend was more evident in the utilization of relievers and CXR for bronchiolitis. The ITS analysis demonstrated that immediately after the publication of the CWC-PHM recommendations, only the use of CXR for asthma decreased significantly. Then, only the use of relievers for bronchiolitis decreased significantly over time in comparison with the secular trend.
