Acute bronchiolitis (AB) is the most frequent lower respiratory tract infection in children aged less than 2 years. It is a major burden in paediatric emergency care services and is the main reason for hospital admission in infants aged less than 1 year,1,2 with an important health care, economic and social impact.3–5

When it comes to the primary care (PC) level, there is a dearth of data on the incidence of AB and the costs associated with its management. According to data from the Autonomous Community of Valencia, 21% of children in the region have at least one episode of AB secondary to infection by respiratory syncytial virus (RSV) in the first year of life, and 87% of paediatric cases of AB are managed in outpatient care services.6

At present, there is no evidence that drugs or other treatments influence the outcome of AB, and supportive measures are the mainstay of its management.7,8 At the PC level, the management of AB should focus on the appropriate clinical diagnosis and assessment of disease severity and hydration status, the identification of children with risk factors for development of severe disease, and lastly providing support and education to the families of children managed in outpatient services.9

However, despite AB being one of the most frequent diseases in the paediatric age group and of the extensive literature available on its management, including clinical practice guidelines with very restrictive indications for the use of bronchodilators (BDs), corticosteroids or antibiotics, the available evidence recurrently describes a frequent use of unnecessary interventions and drugs, and substantial variability in their prescription.10,11

The aim of our study was to assess the impact of a quality improvement initiative that sought to reduce drug prescription for treatment of AB in two primary care service areas.

We conducted a descriptive, community-based pre–post-intervention study with historical controls of 2 consecutive AB epidemic seasons (2015–2016 and 2016–2017) in 2 PC areas in Vizcaya (Basque Country, Spain). We defined the AB epidemic season as ranging from October 1 to March 31. The 2 PC areas comprehend 20 primary care centres (PCCs) with a total of 39 paediatricians in staff currently managing 36,412 children, of who 6371 (17.49%) are aged less than 2 years.

Our study demonstrated that the implementation of a quality improvement intervention at the level of a primary care service area can succeed in reducing the use of pharmacological treatment in the management of AB. However, it also showed that a very high percentage of infants and toddlers with AB continued to be treated with bronchodilators, corticosteroids and antibiotics despite evidence that they are not useful in the management of this disease.13,14 Furthermore, there was considerable variability between clinicians in the prescription of the different drugs, even in a geographical area as small as the PC areas under study.

Clinical practice guidelines are excellent vehicles to inform about good practices and the current scientific evidence on the management of a disease, in this case AB, but their development and dissemination in the scientific literature have proven insufficient to drive change in the clinical practice in many professionals.15,16 Previous studies conducted in hospital settings have demonstrated the usefulness of implementing quality improvement measures at a local level or with collaboration between different settings to improve the management of AB.17–19 Many of the interventions designed to improve the management of AB combine the development of guidelines or local protocols with strategies for their implementation and the education of health care professionals. A study conducted by Ralston et al. to assess a collaborative multicentre strategy18 found a significant decrease in the use of bronchodilators and corticosteroids after the dissemination of the AAP guidelines and education through interactive webinars. Similarly, multifaceted educational bundles, such as the one described by Murch et al.,19 can significantly improve adherence to guidelines. However, no studies to date have been published on similar strategies at the primary care level. Our study shows that approaches similar to those used in hospital settings can achieve a change in clinical practice, in this case, a reduction of 20% in the use of drugs for treatment of AB in PC. The key elements were, on one hand, the dissemination and implementation of a protocol underscoring the most important aspects in the management of children with AB at the PC level, with a restrictive approach regarding the use of bronchodilators in adherence with current recommendations, and on the other hand, and more importantly, the feedback provided to health professionals through the presentation of data on their own clinical practice. This last part is crucial, as there are few published case series of patients managed at the PC level,6,11,20 and professionals need to have access to epidemiological and management data for this care setting.

Multiple studies have called attention to the frequent use of unnecessary interventions in the management of AB.10,21,22 In our study, the excessive use of medication continued to be a problem, since at its conclusion, 52% of children with AB in the PC service area under study continued to receive pharmacological treatment, with a pattern of use that was similar to the patterns reported in the PC literature,11 with the frequent use of combinations of more than 1 drug in a single child (52.3%). It is obvious that there is still ample room for improvement until we reach the awareness that “less is more in bronchiolitis”,23 but this is all the more worrisome at the primary care level, where such a substantial use of drugs can hardly be justified. An interesting finding in our study was that, overall, children aged more than 1 year received a greater number of drugs per patient, 1.84 compared to 1.69 in infants, and that a higher proportion of those aged more than 1 year received more than 1 drug—60.27% compared to 47.5% of infants. This difference is probably due in part to the diagnostic criteria used by clinicians. The more restrictive use of drugs in infants may reflect a better adherence to diagnostic criteria and easier coding and electronic charting in this age group. Children with a previous diagnosis of AB in the first year of life can receive this diagnosis one more time, but are to be managed as children aged more than 2 years with recurrent wheezing episodes, which nowadays would be included under the label of asthma in infants and young children.

Another salient finding in our study was the considerable variability between professionals in the prescription of drugs for treatment of AB. We ought to highlight that while the variability in the prescription of drugs is well known and has been repeatedly described in the literature,10,22 it is not only present between different hospitals within a single country24–26 or a single autonomous community,11 but also, as our study evinced, between PCCs in the same health care system. Furthermore, we found that the PCCs with the highest use of drugs per patient at the outset continued to show this trend after the intervention, which is indicative of the challenges involved in changing long-standing clinical practices. Since the main reason for the excessive use of drugs is not insufficient knowledge of the guidelines, but their modest effectiveness in changing the habitual practices of clinicians, our aim should be not only to update them, but to achieve the maximum impact by developing strategies for their implementation and promoting adherence.22,27 It is key that health care systems become involved in this regard and provide health professionals feedback on their clinical activity, giving them tools for its management, such as in-house indicators and quality standards.

Lastly, we need to improve the knowledge of the general population about AB. In a recent survey,28 19% of clinicians attributed the excessive use of drugs for treatment of AB to the demands made by the family. It is likely that a better understanding of AB, its presentation and its management on the part of parents would facilitate care delivery and reassure both the family and the clinician in charge of its management.

There are limitations to our study. First of all, it only included two PC service areas, so the characteristics of other health care systems could lead to different outcomes of the same intervention. Second, we obtained data retrospectively, which may have resulted in incomplete, heterogeneous or unreliable data. However, we retrieved the data from an electronic system where clinical interventions were recorded at the time they were performed and that was not related to the quality improvement initiative. Third, since this was a community-based pre–post-intervention study, the decline in drug prescription could be due to factors other than the implemented intervention. We do not believe that a greater severity of disease in the second epidemic season was one such factor, as the severity at triage of children managed in the emergency department was the same in both seasons. Fourth, since we only obtained data on drug prescriptions for at-home use and did not investigate the potential administration of bronchodilators at the time of the PC visit, we may have underestimated pharmacological treatment overall. We believe that this potential underestimation would not affect the primary outcome of this intervention, which is the decrease in prescription. Lastly, we did not review patient health records to assess whether clinicians used the McConnochie criteria for diagnosis of AB, as recommended by the established protocol, so that differences between professionals in the applied diagnostic criteria led to overestimation of the incidence of AB. However, the incidence found in our sample was similar to those reported in other studies.

Quality improvement measures implemented at the local level to reduce the use of drugs in the management of AB seem to be effective. Nevertheless, there is still frequent use of pharmacological treatment and great variability between clinicians in the management of the disease, which evinces the need to maintain the current quality improvement interventions and launch new ones. The intervention implemented in this study could be used in other PCCs, where most children with AB are managed in Western countries.

The authors have no conflicts of interest to declare.