Outcomes of Follow-up Visits After Bronchiolitis Hospitalizations

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.

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.

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.

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 measures¹ were high but did not differ between families who did and did not have follow-up.

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.

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 visits² and early (within 1-3 days) follow-up visits³ 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.⁴ Overdiagnosis (detection of conditions where such detection does not benefit patients⁵) and subsequent overtreatment may be 1 explanation for these findings. Additionally, clinic visits may increase the risk of infection transmission.⁶

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.

Accepted for Publication: September 13, 2017.

Corresponding Author: Alan R. Schroeder, MD, Division of Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, 300 Pasteur Dr, MC 5776, Stanford, CA 94305 (aschroe@stanford.edu).

Published Online: January 29, 2018. doi:10.1001/jamapediatrics.2017.4002

Author Contributions: Dr Schroeder had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Schroeder, Destino, Coon.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Schroeder.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Schroeder.

Obtained funding: Schroeder, Coon.

Administrative, technical, or material support: Destino, Wang, Coon.

Study supervision: Coon.

Conflict of Interest Disclosures: None reported.

Funding/Support: Funding for this study was provided by the Department of Pediatrics, Stanford University School of Medicine, by the Division of Pediatric Inpatient Medicine at Primary Children’s Hospital (to support participant enrollment via research assistants), and Intermountain Healthcare via the Stanford Intermountain travel grant to support study planning.

Role of the Funder/Sponsor: The funding sources (Stanford University and Intermountain Healthcare) had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: The authors acknowledge Alicia Harnett from Stanford University for research coordination; Robin Drucker, MD, and Marc Brewer, MD, from Palo Alto Medical Foundation for serving as nonpaid general pediatrician consultants for the design of the study; Heather Oldroyd, Jennifer Nhan, Kristina McKinley, MD, and Miguel Knochel, MD, who enrolled patients through the University of Utah Academic Associates Program; and all of the hospitalists at the Stanford and Intermountain sites who helped or advised with study planning, recruitment, and enrollment of patients. Stanford and Intermountain faculty were given gift cards as a gesture of appreciation for their assistance with enrollment, and Ms Harnett was paid for her research coordination efforts.