WASHINGTON – The use of radiographs, viral testing, steroids, and bronchodilators for young children with bronchiolitis has declined significantly since the introduction of the American Academy of Pediatrics’ diagnostic and management guidelines.
Before the guidelines were released in 2006 (Pediatrics 2006;118:1774-93), use of all these diagnostic and treatment modalities was on the rise, Dr. Kavita Parikh said at the annual meeting of the Pediatric Academic Societies.
Dr. Kavita Parikh
Her retrospective study of more than 130,000 cases demonstrated that the document has had a positive impact on the way bronchiolitis is now managed.
"The AAP practice guideline advocates primarily supportive care," said Dr. Parikh, a pediatric hospitalist at Children’s National Medical Center, Washington. "And as many of us now know, less is more for this illness."
The cases for this study came from a large hospital administration database covering 43 facilities. Dr. Parikh compared diagnostic and treatment resource utilization in three periods: November 2004 to March 2005 (pre-guidelines), November 2007 to March 2008 (early post-guidelines), and November 2011 to March 2012 (late post-guidelines).
The study examined changes in four diagnostic measures (complete blood count [CBC], chest x-rays, respiratory syncytial virus testing, and influenza testing) and three treatment measures (steroids, bronchodilators, and antibiotics).
The study cohort comprised 130,262 children, with a mean age of 4 months. Most (59%) were covered by public insurance.
In the pre-guideline period, CBC was employed in 35% of cases, chest x-ray and RSV testing each in 61%, and influenza testing in 32%. These numbers were essentially unchanged in the early post-guidelines period, but by the late post-guidelines period the recommendations were taking root. All of the measures had decreased significantly: CBC use had gone down by 6%, chest x-rays by about 11%, RSV testing by 20%, and influenza testing by 12%.
Treatment measures changed as well, Dr. Parikh said.
In the pre-guidelines period, steroids were employed in 25% of cases, bronchodilators in 65%, and antibiotics in 34%. Again, the numbers were similar in the early post-guidelines period. By the late post-guidelines period, however, steroid and bronchodilator use had both dropped by 9%. Antibiotic use rose by 3% in the early post-guidelines period but decreased again later for a net change of about 2%. The difference was statistically significant but probably not clinically relevant, Dr. Parikh noted.
"The AAP guidelines have apparently had a positive effect on the way we deal with bronchiolitis, with the greatest impact on chest x-ray, steroid, and bronchodilator use," she said. "We want to continue to look at this and compare local practices to further evaluate implementation by region and hospital type."
Dr. Parikh said that she had no financial disclosures.