Scheduled Follow-Ups May Not Be Necessary for Pediatric Bronchiolitis

Scheduled follow-up visits for children hospitalized with bronchiolitis may not be an absolutely necessary practice in the effort of reducing their parents’ anxieties, according to new findings.

In an assessment that gauged parents’ perspectives on either scheduled or as-needed post-hospitalization follow-up visits for their children who suffered from bronchiolitis, a team of Utah- and California-based investigators found the latter was noninferior to the former.

The findings also showed either practice did not significantly differ in health-related outcomes, including readmission and symptom duration.

Investigators, led by Eric R. Coon, MD, MS, of the Primary Children’s Hospital at the University of Utah School of Medicine, conducted the randomized, controlled Bronchiolitis Follow-up Intervention Trial (BeneFIT) involving 304 children hospitalized for bronchiolitis at both Coon and colleague’s facility, as well as the Lucile Packard Children’s Hospital in Palo Alto, CA.

Patients were randomized 1:1 to either scheduled (n = 151) or as-needed (n = 153) posthospitalization follow-up visits. The team’s assessment was conducted from January 2018 — April 2019.

Coons and colleagues sought a primary outcome of parental anxiety in the 7 days following hospital discharged, as per the anxiety portion of the Hospital Anxiety and Depression Scale, a 0-28 point metric in which greater scores indicate greater anxiety.

Among the 14 prespecified secondary outcomes were metrics of overall patient health posthospitalization.

Median patient age was 8 months old (IQR, 3-14 months) and a majority of 59% were male. Investigators had available data for 269 of the observed patients.

Among the scheduled follow-up group, 106 children (81%) attended a scheduled posthospitalization visit—versus just 26 children (19%) in the as-needed group (absolute difference, 62%; 95% CI, 53-71).

Mean seven-day parental anxiety score was 3.9 among the as-needed posthospitalization follow-up group, and 4.2 among the scheduled group (absolute difference, -0.3 points; 95% CI, -1.0 to 0.4).

The team observed no significant differences for secondary outcomes including readmissions, as per any hospital readmission prior to symptom resolution, and symptom duration, as per time from discharge to resolution of cough and child-reported signs of “back to normal.”

Coons and colleagues noted this is the first randomized clinical trial to assess metrics of value in scheduled posthospitalization follow-up visits. Previous trials, involving adult patients, have focused on the value of posthospitalization follow-up for reducing hospital revisits—but adults are more frequently burdened by chronic conditions, and less likely to be hospitalized for diseases that often resolve.

“This generally reassuring prognosis may explain why studies of scheduled follow-up among children have rarely demonstrated a benefit,” they wrote.

In an editorial accompanying the new study, Jay G. Berry, MD, MPH, and Jonathan M. Mansbach, MD, MPH, both of Boston’s Children Hospital and Harvard Medical School, wrote the findings are impactful in the scope of outpatient reprioritization during the coronavirus 2019 (COVID-19) pandemic.

“As COVID-19 becomes less prevalent and clinics reopen, patients and clinicians will continue to weigh the risks and benefits of face-to-face outpatient health care encounters,” they wrote.

Coon’s and colleagues’ use of the noninferiority outcome in their trial, they wrote, requires a measured interpretation of their findings—noninferiority trials do not offer hypotheses, statistical analysis, or superiority positioning in care.

Despite this limitation, the pair expressed hope that the findings prompt a greater mindfulness among clinicians tasked with scheduling follow-up care for hospitalized children with bronchiolitis.

“Future studies should assess the utility of as-needed visits for children hospitalized with other acute, self-limited illnesses beyond bronchiolitis,” they wrote.

The study, “Comparison of As-Needed and Scheduled Posthospitalization Follow-up for Children Hospitalized for Bronchiolitis,” was published online in JAMA Pediatrics.