Section of Pediatric Hospital Medicine, Children's Hospital Colorado (A Tyler), Aurora, Colo; Department of Pediatrics, University of Colorado School of Medicine (A Tyler, A Dempsey, and J Freeman), Aurora, Colo; Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado (A Tyler, A Dempsey, R Marsh, and MA Morris), Aurora, Colo.
Department of Pediatrics, University of Colorado School of Medicine (A Tyler, A Dempsey, and J Freeman), Aurora, Colo; Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado (A Tyler, A Dempsey, R Marsh, and MA Morris), Aurora, Colo.
Acad Pediatr. 2022 Jul;22(5):806-817. doi: 10.1016/j.acap.2021.08.003. Epub 2021 Aug 8.
Clinical practice guidelines for bronchiolitis recommend against tests and treatments that do not improve outcomes, yet most children admitted with bronchiolitis continue to receive them. An improved understanding of factors that influence care decisions across multiple stakeholders and diverse settings is needed to develop effective strategies to de-implement (or reduce) unnecessary testing and treatment.
We explored health care provider, care team, and parent perspectives on testing and treatment in bronchiolitis to develop a combined stakeholder account of care decisions. We conducted a qualitative case study across 2 geographically distinct university affiliated children's hospitals representing a generally low and high test/treatment utilizing hospital respectively from March 2019 to May 2020. We conducted 46 semistructured interviews and 3 focus groups with a total of 74 participants. Data were analyzed using applied thematic analysis and findings were triangulated across participant group and data collection method.
Three themes emerged around care decisions: 1) awareness and perceptions of the guidelines or evidence; 2) perceptions of expected tests or treatments, and 3) organizational culture and existing care processes. Provider and care team participants commonly described parent expectations as drivers of utilization. Conversely, parents generally reported a lack of expectations for tests/treatments and that tests/treatments did not improve their experience of care.
This study illuminated factors associated with the differential adoption of evidence and targets for future de-implementation strategies. Importantly, incongruent with provider and care team perceptions, parents reported that they desire an evidence-based, less-is-more approach to bronchiolitis care.
毛细支气管炎的临床实践指南建议避免使用不能改善结局的检查和治疗，但大多数因毛细支气管炎入院的儿童仍在接受这些检查和治疗。为了制定有效的去执行（或减少）不必要的检查和治疗的策略，需要更好地了解影响多利益相关者和不同环境下的护理决策的因素。
我们探讨了医疗保健提供者、护理团队和父母对毛细支气管炎检查和治疗的看法，以制定一个综合的利益相关者护理决策账户。我们在 2019 年 3 月至 2020 年 5 月期间在两家地理位置不同的附属儿童医院进行了一项定性案例研究，这两家医院分别代表了通常低和高测试/治疗利用率的医院。我们共进行了 46 次半结构化访谈和 3 次焦点小组，共有 74 名参与者。使用应用主题分析对数据进行分析，并在参与者群体和数据收集方法之间进行了发现的三角测量。
护理决策有三个主题：1）对指南或证据的认识和看法；2）对预期的检查或治疗的看法；3）组织文化和现有的护理流程。提供者和护理团队参与者通常将家长的期望描述为利用率的驱动因素。相反，父母通常报告他们对检查/治疗的期望较低，并且检查/治疗并没有改善他们的护理体验。
本研究阐明了与证据的不同采用以及未来去执行策略的目标相关的因素。重要的是，与提供者和护理团队的看法不一致，父母报告说他们希望对毛细支气管炎护理采取基于证据、少即是多的方法。
