Abstract
This cohort study examines the frequency of postdischarge follow-up visits among US emergency department encounters for bronchiolitis and assesses whether follow-up was associated with decreased hospital reutilization or increased treatment with nonrecommended medications.
Introduction
Although the value of routine posthospitalization follow-up visits for otherwise healthy children with acute bronchiolitis has been questioned,1 less is known about the value of follow-up for children discharged from the emergency department (ED). Follow-up visits offer an opportunity to reassess the clinical trajectory and to provide reassurance to families, but they also may result in financial costs, missed work, and overtreatment.2 Although anecdotal evidence suggests that recommending postdischarge follow-up is the default practice for many ED clinicians, to our knowledge, national practice patterns have not been described. Our objectives were to describe the frequency of postdischarge follow-up visits in a national cohort of ED encounters for bronchiolitis and to assess whether follow-up was associated with decreased hospital reutilization or increased treatment with nonrecommended medications.
Methods
This was a retrospective cohort study of ED discharges between 2018 and 2021 among children with commercial insurance aged less than 2 years with acute bronchiolitis in the MarketScan Commercial Claims and Encounters Database.3 The database includes insurance claims for more than 30 million employees and their dependents in the United States. We excluded children with complex chronic conditions.4 The Harvard Pilgrim Health Care Institute institutional review board approved this study. The need for informed consent was waived because data were obtained in a deidentified format. We followed the STROBE reporting guideline.
The primary outcome was a follow-up visit in primary care within 7 days of ED discharge. The secondary outcomes were ED revisits without hospitalization, hospitalization, and dispensation of medications not recommended by national guidelines (albuterol, corticosteroids, antibiotics).5 Administrative codes are listed in the eAppendix in Supplement 1.
We used Poisson regression with robust clustered SEs to identify characteristics associated with attending follow-up. We clustered on individuals to account for nonindependence of observations among children with more than 1 illness episode. To assess the association between follow-up and subsequent hospital reutilization, we used multivariable Cox proportional hazard models. These models included follow-up as a time-varying exposure and adjusted for year, age, sex, region, weekend discharge, number of outpatient and ED visits in the prior year, whether there was an outpatient visit for bronchiolitis in the 7 days prior to the index ED visit, and testing (viral testing, chest radiography) and treatments (albuterol, corticosteroids, antibiotics) at the index visit. Statistical significance was considered at a 2-sided P < .05. Analyses were performed using R version 3.2.1 (R Project for Statistical Computing) from December 2022 to July 2023.
Results
Among 28 338 ED discharges (27 000 unique patients), 63.3% (95% CI, 62.8%-63.9%) were less than 1 year of age and 58.8% (95% CI, 58.2%-59.3%) were male. Follow-up within 7 days occurred for 47.6% (95% CI, 47.0%-48.1%) of discharges. The proportion of discharges with follow-up decreased from 48.9% (95% CI, 47.9%-49.9%) in 2018 to 43.4% (95% CI, 42.2%-44.5%) in 2021 (P < .001). Several demographic and clinical characteristics were associated with follow-up (Table 1).
Table 1. Characteristics of the Cohort and Attending a Follow-Up Visit (N = 28 338).
| Characteristic | Proportion of discharges, % (95% CI) | Follow-up visit, adjusted risk ratio (95% CI)a | |
|---|---|---|---|
| Without follow-up visit (n = 14 862) | With follow-up visit (n = 13 476) | ||
| Year | |||
| 2018 | 30.3 (29.5-31.0) | 31.9 (31.1-32.7) | 1 [Reference] |
| 2019 | 30.2 (29.5-31.0) | 33.6 (32.8-34.4) | 0.96 (0.93-0.98) |
| 2020 | 13.1 (12.6-13.7) | 12.2 (11.6-12.7) | 0.88 (0.85-0.92) |
| 2021 | 26.4 (25.7-27.1) | 22.3 (21.6-23.0) | 0.85 (0.82-0.88) |
| Age >1 y | 40.1 (39.4-40.9) | 32.8 (32.0-33.6) | 0.83 (0.81-0.85) |
| Sex | |||
| Male | 58.7 (57.9-59.5) | 58.8 (58.0-59.7) | 1.00 (0.97 to 1.02) |
| Female | 41.3 (40.5-42.1) | 41.2 (40.3-42.0) | 1 [Reference] |
| United States Census region | |||
| Northeast | 12.4 (11.8-12.9) | 15.4 (14.8-16.0) | 1 [Reference] |
| North central | 28.8 (28.1-29.5) | 26.0 (25.2-26.7) | 0.87 (0.84-0.90) |
| South | 44.9 (44.1-45.7) | 43.5 (42.7-44.3) | 0.89 (0.86-0.92) |
| West | 13.9 (13.4-14.5) | 15.1 (14.5-15.8) | 0.98 (0.95-1.03) |
| Weekend discharge | 30.4 (29.7-31.2) | 33.4 (32.6-34.2) | 1.07 (1.05-1.10) |
| Outpatient visit for bronchiolitis within 7 d prior to the index visit | 25.0 (24.3-25.7) | 31.0 (30.2-31.8) | 1.12 (1.09-1.15) |
| No. of outpatient visits in the prior year, median (IQR) | 5 (2-8) | 5 (3-9) | 1.03 (1.02-1.03) |
| Any emergency department visit in the prior year | 32.1 (31.4-32.9) | 28.8 (28.0-29.6) | 0.90 (0.87-0.92) |
| Testing and treatment at the index visit | |||
| Viral testing | 41.1 (40.4-41.9) | 43.9 (43.0-44.7) | 1.08 (1.05-1.10) |
| Chest radiography | 40.0 (39.2-40.8) | 41.1 (40.3-42.0) | 1.02 (0.99-1.05) |
| Albuterol | 21.6 (21.0-22.3) | 24.5 (23.8-25.3) | 1.07 (1.04-1.11) |
| Corticosteroids | 9.5 (9.0-9.9) | 10.1 (9.6-10.6) | 1.02 (0.98-1.06) |
| Intravenous fluids | 3.6 (3.3-3.9) | 5.1 (4.8-5.5) | 1.15 (1.10-1.21) |
Adjusted risk ratios are from a multivariable Poisson regression model with robust clustered standard errors. Clustering was performed at the level of the patient.
Within 7 days after discharge, 17.6% (95% CI, 17.1%-18.0%) of discharges had an ED revisit and 5.2% (95% CI, 5.0%-5.5%) were subsequently hospitalized. Follow-up was not associated with ED revisits (adjusted hazard ratio [HR], 1.09; 95% CI, 0.93-1.27) but was positively associated with subsequent hospitalization (adjusted HR, 1.41; 95% CI, 1.20-1.65). Prescriptions for albuterol, corticosteroids, and antibiotics were filled more frequently among children who attended follow-up (Table 2). Among children who attended follow-up, 12.2% (95% CI, 11.5%-12.8%) filled a prescription for albuterol, 5.4% (95% CI, 4.9%-5.9%) for corticosteroids, and 18.5% (95% CI, 17.8%-19.3%) for antibiotics after the follow-up visit.
Table 2. Medications Dispensed After Discharge, Stratified by Follow-Up Status.
| Medication | Proportion with medication dispensation, % (95% CI) | P valuea | |
|---|---|---|---|
| No follow-up | Follow-up | ||
| Albuterol | 15.0 (14.4-15.7) | 26.6 (25.8-27.5) | <.001 |
| Corticosteroids | 9.9 (9.4-10.5) | 13.4 (12.7-14.1) | <.001 |
| Antibiotics | 16.3 (15.6-17.0) | 30.4 (29.5-31.4) | <.001 |
P values are from χ2 test.
Discussion
Approximately half of commercially insured children with acute bronchiolitis completed a follow-up visit within 7 days of ED discharge. Follow-up visits were not associated with ED revisits. The association between follow-up and hospitalization could be explained by confounding by indication (ie, children with more severe illness may be more likely both to follow up and to be hospitalized) or by overdiagnosis at follow-up.6 Nonrecommended medications were dispensed for a modest proportion of children after follow-up. Limitations of this study included incomplete data to adjust for clinical severity, an inability to distinguish scheduled from unscheduled follow-up visits, and inclusion of only patients with commercial insurance. Given that follow-up visits are common, vary in frequency according to visit characteristics, have uncertain benefits, may result in overtreatment, and carry costs to families and the health care system, prospective investigation is warranted to determine which children with bronchiolitis may benefit from routine follow-up.
eAppendix. Administrative Codes
Data Sharing Statement
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eAppendix. Administrative Codes
Data Sharing Statement