Research In Practice Blog

Bronchiolitis
Transforming Pediatric Care through a nearly $7 Million Award for I-DECIDE Trial on Family-Centered Approaches to Bronchiolitis Follow-Up
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By Atyia Collins

Researchers from Clinical Futures, a Research Institute Center of Emphasis at Children’s Hospital of Pennsylvania (CHOP) and Seattle Children's Research Institute, have been awarded nearly $7 million in funding to create an effectiveness-implementation trial focused on deimplementing unnecessary follow-ups in primary care after bronchiolitis hospitalization across the US.  The funding was awarded by the Patient-Centered Outcomes Research Institute (PCORI), an independent, nonprofit organization that is the leading funder of patient-centered comparative clinical effectiveness research in the United States.  

Bronchiolitis is a common lung infection, responsible for over 100,000 pediatric hospitalizations annually and a majority of children hospitalized for bronchiolitis attend follow-up visits within days of discharge.  Research has shown that these visits are often unnecessary after hospitalizations caused by bronchiolitis and the American Academy of Pediatrics recommends pro re nata (PRN) or "as needed" post-hospitalization follow-up for children hospitalized for bronchiolitis.

Follow-up visits are time consuming for physicians and clinic staff, and result in missed work, missed school, and additional time spent, insurance co-pays and transportation costs for families. These burdens disproportionately affect minoritized and low-income families. Ensuring that children receive appropriate post-hospitalization follow-up while minimizing further disruption to family routines is a key component of family-centered care.

Developing Strategies and Implementation Tools

The study, titled Implementing family Directed and Empowered Care with Infant Discharge Evidence (I-DECIDE), will compare two multicomponent implementation strategies aiming to increase adoption and sustained implementation of PRN (as-needed) follow-up after a hospitalization for bronchiolitis.

Chris Bonafide, MD, MSCE, Associate Chief of the Division of General Pediatrics and Co-Associate Director for Implementation Science of Clinical Futures at CHOP, is a Multiple Principal Investigator (MPI) on the study, along with Dr. Eric Coon, an attending physician and a researcher at the Seattle Children’s Research Institute and a Professor of Pediatrics at the University of Washington. Dr. Coon served as a principal investigator for the Bronchiolitis Follow-up Intervention Trial (BeneFIT), which compared as-needed post hospitalization follow-up to automatic post-hospitalization follow-up, finding that as-needed follow-up is a promising post-hospitalization follow-up strategy for children with bronchiolitis.

    I-DECIDE will compare two multicomponent implementation strategies to increase adoption and sustained implementation of PRN follow-up after a hospitalization for bronchiolitis. These strategies include;

  1. The moderate-resource strategy includes educational outreach, audit and feedback, and materials for electronic health record (EHR) and clinical decision support (CDS).
  2. The high-resource implementation strategy includes all moderate-resource strategy components plus two forms of external facilitation: small-group and expert CDS coaching.

Methodology

As a hybrid type 3 effectiveness-implementation trial, I-DECIDE will focus primarily on implementation of a recommended but underutilized intervention (PRN follow-up) and secondarily on further examination of effectiveness of the intervention.

The study’s three main aims include;

  • Compare the effect of a moderate- versus high-resource implementation strategy on short-term changes (initial adoption) of PRN follow-up prescribing by hospitalists and on long-term changes (sustainment) of post-hospitalization follow-up visit attendance by families while closely examining adoption equity.
  • Examine the effectiveness of PRN follow-up prescribing for patient-centered outcomes and subsequent healthcare utilization.
  • Identify implementation strategy mechanisms linked to adoption and sustainment of PRN follow-up.

“In I-DECIDE, we really want to know what’s the best way to get as-needed follow-up rolled out on a large scale.” said Dr. Bonafide. “We’re looking at the barriers and the reasons why as-needed follow-up isn’t being used right now and studying how we can match those barriers with different potential strategies so that we have a good outcome. That includes as-needed follow-up widely adopted initially and then sustained over time.”

Data collection for I-DECIDE is comprised of 3 phases, 6 months in duration each. Researchers will deploy the moderate- and high-resource strategies according to each hospital’s randomized assignment and, after a washout period, assess how well reductions in post-hospitalization follow-visits were sustained after the washout period.

Partners and Collaborators  

I-DECIDE is a collaboration between experienced investigators, important stakeholders, and organizations with expertise in facilitating multicenter research. Dual-PIs Dr. Coon and Dr. Bonafide will lead the study.  

"I am thrilled to get started on the I-DECIDE trial and thankful to PCORI for the funding that will allow us to begin this collaborative effort with Dr. Coon.  The study has the potential to help healthcare organizations and service providers increase the effective use of interventions within primary care after bronchiolitis hospitalization. We hope our results give guidance on enhancing quality of life and promoting greater personal agency for individuals across diverse populations." Dr. Bonafide

“Dr. Bonafide and I are excited about the opportunity to conduct the I-DECIDE trial, funded by PCORI. I-DECIDE has the potential to increase the practice of as-needed post-hospitalization follow-up for children with bronchiolitis. As-needed follow-up in this population is evidence-based and less burdensome on families and the healthcare system but infrequently utilized by clinicians. We’re comparing two different implementation strategies across 30 hospitals to determine which one leads to the greatest uptake of as-needed follow-up,” said Dr. Coon.

I-DECIDE hospitals are members of the Pediatric Research in Inpatient Settings (PRIS) Network. The I-DECIDE Implementation Science Core will be located within Clinical Futures and directed by Dual-PI Bonafide. Clinical Futures faculty members Gwendolyn Lawson, PhD, Halley Ruppel, PhD, RN and Brooke Luo, MD will be co-investigators on the study.

Research in Practice Implications

I-DECIDE addresses a clinical decision gap by supporting clinicians and families with the tools (e.g., education, CDS) they need to adopt PRN follow-up as the new status quo. Second, I-DECIDE addresses an equity gap in burden of automatic follow-up care and access to PRN follow-up care. I-DECIDE promotes more equitable access to PRN follow-up through approaches that are patient-facing (e.g., families who speak 10 most common languages beyond English are eligible and all materials are translated, including reasons to seek follow-up care) and clinician-facing (e.g., dashboard displaying hospital-level rates of PRN follow-up prescribing stratified by race, ethnicity, and spoken language).

“We’re putting It in the family's hands to decide what’s best for them. We’re not saying don’t go to that visit, we’re really empowering them and saying we trust you to decide if your child needs more medical care in the next few days.” said Dr. Coon. 

Learn more in this CHOP press release and on PCORI’s website.