As-Needed vs Scheduled Posthospitalization Follow-up for Children With Bronchiolitis
Jordan N. Watson, MD
Nemours/Alfred I. duPont Hospital for Children
Watson JN. As-needed vs scheduled posthospitalization follow-up for children with bronchiolitis. Consultant360. Published online August 13, 2020.
Coon ER, Destino LA, Greene TH, Vukin E, Stoddard G, Schroeder AR. Comparison of as-needed and scheduled posthospitalization follow-up for children hospitalized for bronchiolitis: the Bronchiolitis Follow-up Intervention Trial (BeneFIT) randomized clinical trial. JAMA Pediatr. Published online July 6, 2020. https://doi.org/10.1001/jamapediatrics.2020.1937
The era of COVID-19 has forced the medical community to examine the necessity of each in-person office visit and create alternatives to provide comprehensive, accessible medical care while reducing risk of exposure to patients and staff. As the fall approaches with no steady decline in COVID-19 cases nationwide, we need to anticipate how we will provide care for our patients as we start to see other seasonal respiratory viruses and an increase in volume of patients with febrile respiratory illnesses. A recent study in JAMA Pediatrics examined the impact on caregiver anxiety for as-needed vs scheduled posthospitalization follow-up for children hospitalized with bronchiolitis.1
The Bronchiolitis Follow-Up Intervention Trial (BeneFIT) is an open-label, noninferiority randomized clinical trial conducted over a 16-month period in 2018 and 2019 and included 2 children’s hospitals and 2 community hospitals. Due to the self-limited nature of bronchiolitis and prior data indicating caregiver reassurance as a benefit for posthospitalization bronchiolitis follow-up, the primary outcome of this study was parental anxiety 7 days posthospital discharge.
There were 14 secondary outcomes also examined, including missed days from work and daycare, number of post-discharge ambulatory visits, risk of hospital re-admissions and emergency department visits prior to symptom resolution, time to resolution of symptoms, and parental satisfaction outcomes.
In all, 304 children were included in the study and randomly assigned to either have a scheduled follow-up visit or an as-needed follow up visit with their primary care practitioner (PCP). The study included children younger than 24 months with an admission diagnosis of bronchiolitis who did not have an underlying chronic medical condition including chronic lung disease or complex heart disease. Additional exclusion criteria included whether the medical provider or PCP wanted a scheduled follow-up visit for the patient and whether the patient was being discharged on oxygen. The study did include patients who presumably had or would be more likely to have severe illness—those who were admitted to the intensive care unit and required respiratory support including BiPAP, CPAP, and ventilator support and patients younger than 2 months.
Overall, 81% of the children in the scheduled follow-up group vs 19% of the children in the as-needed group attended a follow-up visit after discharge. Parental anxiety was measured using the Hospital Anxiety and Depression Scale within 2 days prior to hospital discharge and 7 days after hospital discharge. Data was collected via telephone interview every 7 days after hospital discharge until symptom resolution or 50 days after discharge, whichever came first. There was no statistically significant difference in the mean 7-day parental anxiety between the study groups.
For secondary outcomes, the as-needed follow-up group had fewer clinic visits with an absolute mean difference of -0.6 and had less ambulatory testing (primarily pulse oximetry) than the scheduled follow-up group. There were no other significant differences in secondary outcomes among the 2 groups, though the authors noted that the trial was not powered to detect differences in hospital revisits.
Limitations of the study noted by the authors included the exclusion of patients for whom the medical provider wanted scheduled follow-up and those with significant comorbidities, limiting ability to generalize findings with all patients. There also is the risk of bias with both the use of survey questionnaires and in an open-label trial.
PCP perspectives were also not evaluated in this study. As a general pediatrician who cares for patients with bronchiolitis in both the inpatient and outpatient settings, patients whom I am more concerned about post-bronchiolitis hospitalization include infants younger than 3 months, those with comorbidities, and infants and toddlers with recurrent bronchiolitis or viral-induced wheezing. Two of these groups were included in the study. For patient populations for whom the PCP is concerned, telemedicine follow-ups could be utilized, reducing the need for an office visit and unnecessary testing, unless there are specific concerns.
A 2017 study2 in Pediatrics examined 30-day pediatric readmissions after lower respiratory tract infections, including bronchiolitis. There were significant differences in readmission rates among hospitals in the study. We should continue to gather data from the literature and within our institutions to identify risk factors for readmission and explore creative ways to provide patient-centered care within the medical home, including posthospitalization discharge.
Jordan N. Watson, MD, FAAP, is clinical assistant professor of pediatrics at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania. She is a general pediatrician and a dermatology access physician in the Division of General Pediatrics and the Division of Dermatology at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware.
- Coon ER, Destino LA, Greene TH, Vukin E, Stoddard G, Schroeder AR. Comparison of as-needed and scheduled posthospitalization follow-up for children hospitalized for bronchiolitis: the Bronchiolitis Follow-up Intervention Trial (BeneFIT) randomized clinical trial. JAMA Pediatr. Published online July 6, 2020. https://doi.org/10.1001/jamapediatrics.2020.1937
- Nakamura MM, Zaslavsky AM, Toomey SL, et al. Pediatric readmissions after hospitalizations for lower respiratory infections. Pediatrics. 2017;140(2):e20160938. https://doi.org/10.1542/peds.2016-0938