Abstract
This survey study of families of children younger than 2 years discharged after hospitalization for bronchiolitis assesses the usefulness of routine outpatient follow-up after hospitalization.
Bronchiolitis is a common, self-limited condition with few effective, evidence-based therapeutic interventions. To our knowledge, none of the numerous recent efforts to improve value in bronchiolitis care have addressed routine outpatient follow-up after hospitalization, a common yet understudied intervention.
Methods
Between December 1, 2016, and March 31, 2017, we conducted a multicenter prospective study involving children younger than 2 years hospitalized with an attending diagnosis of bronchiolitis at 1 of 5 hospitals affiliated with Stanford Children’s Health and Intermountain Healthcare in Utah. Participants with congenital heart disease, chronic lung disease, neuromuscular disease, immunodeficiencies, or malignant neoplasms were excluded, as were patients discharged using supplemental oxygen.
The investigation involved no clinical interventions. Families were contacted 5 to 8 days following discharge and weekly thereafter until symptom resolution to assess the occurrence and outcomes of any health care encounters, and their perceptions of these encounters via scripted questionnaires. Institutional review board approval from all sites and written informed consent from parents/legal guardians were obtained.
Results
We invited a convenience sample of 344 families to participate; 76 (22%) declined and 70 patients (20%) were discharged using supplemental oxygen, leaving 198 enrolled participants (Table 1); telephone follow-up through symptom resolution was completed on 166 (84%). Most families (166 of 198 [84%]) received discharge recommendations for clinic follow-up, and 112 of 169 (66%) participants contacted at 1 week had undergone at least 1 clinic visit within 8 days of discharge. Visits were more likely if the appointment was scheduled prior to discharge compared with instructing the family to make the appointment (27 of 31 [87%] vs 76 of 111 [68%]; P = .04). New prescriptions were provided for 13 of 112 (12%) participants during these visits. Only 3 patients (2%) were readmitted to the hospital; all 3 had routine follow-up visits.
Table 1. Baseline Characteristics of Enrolled Participants.
| Characteristic | Value (N = 198) |
|---|---|
| Age, median (IQR), mo | 5.4 (1.9-13) |
| Female sex, No. (%) | 81 (41) |
| Nonwhite race, No. (%) | 98 (49) |
| Government insurance, No. (%) | 91 (46) |
| Any prior medical history, No. (%)a | 55 (28) |
| Intensive care unit stay during hospitalization, No. (%) | 69 (35) |
| Hospital length of stay, median (IQR), d | 2 (1-4) |
| ≥1 Medications prescribed at discharge, No. (%)b | 52 (26) |
Abbreviation: IQR, interquartile range.
Prior premature birth (n = 22), wheezing (n = 18), eczema (n = 12), other (n = 7).
Oral antibiotics (n = 36), β agonists (n = 18), systemic steroids (n = 2), inhaled steroids (n = 1).
Families believed that office visits were a good use of their time (Table 2). “Reassurance” was selected most commonly (73 of 104 [70%]) from the choices provided as the most useful aspect of the visit. Overall health care satisfaction measures were high but did not differ between families who did and did not have follow-up.
Table 2. Outcomes of Follow-up Visits.
| Outcome | Value |
|---|---|
| Any office visit (stratified by follow-up plan), proportion (%)a | 112/169 (66) |
| Visit recommended, clinic appointment made prior to discharge | 27/31 (87) |
| Visit recommended, family instructed to make appointment | 76/111 (68) |
| Visit recommended, no time range suggested | 0/2 |
| Visit recommended only if worsening symptoms | 4/12 (33) |
| No follow-up plan noted | 5/13 (38) |
| Saw primary care physician at office visit, No. (%) | 75 (67) |
| ≥1 New prescription provided, No. (%) | 13 (12) |
| Breathing treatment | 8 (7) |
| Corticosteroids | 2 (2) |
| Antibioticb | 7 (6) |
| “(Routine) visit was a good use of my or my family’s time,” No. (%) | |
| Strongly agree | 55 (50) |
| Agree | 49 (45) |
| Uncertain | 2 (2) |
| Disagree | 4 (4) |
| Strongly disagree | 0 |
| “Which aspect of visit was most useful?”c | |
| New treatment provided | 6 (6) |
| Treatment(s) were stopped | 2 (2) |
| Reassurance provided | 73 (70) |
| Education provided | 15 (14) |
| Don’t know | 3 (3) |
| Otherd | 5 (5) |
Follow-up plan ascertained by medical record review.
For pneumonia (n = 1) and otitis media (n = 6).
Was only asked to families who agreed or strongly agreed that visit was a good use of time; respondents were asked to choose the 1 best answer.
Help with suctioning (n = 2), oxygen measurement (n = 1), readmitted (n = 2).
The median duration of cough following discharge was 6 (interquartile range, 3-9) days, with 19 of 166 (11%) participants having a cough for 2 weeks or more.
Discussion
Routine follow-up visits were frequently recommended following bronchiolitis hospitalizations, and occurred in approximately two-thirds of patients. While new treatments were uncommonly provided, visits seemed to provide families with reassurance.
Although generally considered standard practice, the value of routine postdischarge visits has not been rigorously evaluated. These visits seem to provide reassurance and may provide other benefits not measured in our study, including opportunities for catch-up vaccination or counseling for new problems. However, they also have associated costs and may have potential risks. Recent retrospective investigations into pediatric hospital discharges demonstrated a significant positive association between any follow-up visits and early (within 1-3 days) follow-up visits and subsequent hospital readmission. Although confounding by indication may explain these associations, a recent randomized clinical trial demonstrated that a nurse-led home visit after discharge was associated with increased readmission and emergency department visits compared with standard care. Overdiagnosis (detection of conditions where such detection does not benefit patients) and subsequent overtreatment may be 1 explanation for these findings. Additionally, clinic visits may increase the risk of infection transmission.
The data obtained from this study are being used to inform the planning of the Bronchiolitis Follow-up Intervention Trial (BeneFIT, NCT03354325), a multicenter randomized clinical trial comparing scheduled vs “as needed” clinic follow-up visits. Similar investigations are needed to analyze follow-up care for other acute conditions (eg, pneumonia, gastroenteritis, skin and soft-tissue infections, febrile infant) in children in which disease is self-limited and clinical improvement is expected. Telephone follow-up or video-conferencing are potential alternatives to scheduled follow-up visits. Lack of reimbursement may limit their uptake, but these approaches may provide equivalent family reassurance, education, and satisfaction while limiting the risks and costs associated with increased health care exposure.
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