Article: 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. 2020 Sep 1;174(9):e201937. doi: 10.1001/jamapediatrics.2020.1937. Epub 2020 Sep 8. PMID: 32628250; PMCID: PMC7489830.
Fellow: Lauren McGill, MD | PGY-5 | Tufts Children’s Hospital
Summary: For otherwise healthy children who are being discharged after hospitalization for bronchiolitis, it is expected that they will have quick resolution of their symptoms following discharge and are at low risk for readmission. Despite this expectation of continued clinical improvement, parents are often instructed to schedule a primary care physician (PCP) follow-up visit. The Bronchiolitis Follow-up Intervention Trial (BeneFIT) was an open-label, non-inferiority randomized controlled trial (RCT) comparing outcome measures of as-needed PCP follow-up visits to scheduled PCP follow-up visits after hospital discharge for children admitted for bronchiolitis at 4 different hospitals (2 free-standing children’s hospitals and 2 community hospitals) over a 16-month period. Given that parental reassurance had previously been reported as a valuable benefit of scheduled follow-up visits, parental anxiety (measured at 7 days after hospital discharge using the Hospital Anxiety and Depression Scale) was selected as the primary outcome of the study, and as-needed PCP follow-up visits were found to be non-inferior to scheduled PCP follow-up visits. Fourteen secondary outcomes were also measured. Twelve of the fourteen secondary outcomes, including rates of hospital readmission and emergency department (ED) visits before symptom resolution, were not significantly different between the two groups. The only two secondary outcomes that were significantly different were the number of clinic visits before symptom resolution and any testing (including pulse oximetry) performed at the first ambulatory visit.
Key Strengths: Other studies looking at the effects of hospital follow-up visits have been observational in nature, and as of the time of article publication, this was the only RCT investigating these effects. This study utilized a validated scale for the primary outcome and also used validated tools for some of the secondary outcomes. Another strength of this study is that it included patients admitted to both free-standing children’s hospitals and community hospitals, thus contributing to greater generalizability for various inpatient practice settings.
Limitations/Flaws: Certain patients were excluded from this study, which limits generalizability for those specific populations. Excluded patients included those with a history of certain medical conditions (chronic lung disease, complex or hemodynamically significant heart disease, immunodeficiency, or neuromuscular disease), the need for continued narcotic or benzodiazepine wean at the time of hospital discharge, or the need for home oxygen therapy. Other limitations included the lack of standardization of the follow-up visit and the possible introduction of bias given the open-label trial design. The authors also noted that their study was not powered to detect some of the possible benefits of scheduled follow-up, such as earlier recognition of respiratory compromise. Additionally, PCP perspectives on scheduled versus as-needed follow-up visits were not obtained.
Takeaway Message: With regards to reducing parental anxiety, as-needed PCP follow-up visits were non-inferior to scheduled PCP follow-up visits in otherwise healthy children discharged from the hospital after admission for bronchiolitis. Also, there was no significant difference in hospital readmissions or ED visits between the two groups.
Practice Impact: Hospital providers may recommend as-needed PCP follow-up for children who were admitted for bronchiolitis and who do not have significant medical comorbidities.
Fellow: Lauren McGill, MD | PGY-5 | Tufts Children’s Hospital
Summary: For otherwise healthy children who are being discharged after hospitalization for bronchiolitis, it is expected that they will have quick resolution of their symptoms following discharge and are at low risk for readmission. Despite this expectation of continued clinical improvement, parents are often instructed to schedule a primary care physician (PCP) follow-up visit. The Bronchiolitis Follow-up Intervention Trial (BeneFIT) was an open-label, non-inferiority randomized controlled trial (RCT) comparing outcome measures of as-needed PCP follow-up visits to scheduled PCP follow-up visits after hospital discharge for children admitted for bronchiolitis at 4 different hospitals (2 free-standing children’s hospitals and 2 community hospitals) over a 16-month period. Given that parental reassurance had previously been reported as a valuable benefit of scheduled follow-up visits, parental anxiety (measured at 7 days after hospital discharge using the Hospital Anxiety and Depression Scale) was selected as the primary outcome of the study, and as-needed PCP follow-up visits were found to be non-inferior to scheduled PCP follow-up visits. Fourteen secondary outcomes were also measured. Twelve of the fourteen secondary outcomes, including rates of hospital readmission and emergency department (ED) visits before symptom resolution, were not significantly different between the two groups. The only two secondary outcomes that were significantly different were the number of clinic visits before symptom resolution and any testing (including pulse oximetry) performed at the first ambulatory visit.
Key Strengths: Other studies looking at the effects of hospital follow-up visits have been observational in nature, and as of the time of article publication, this was the only RCT investigating these effects. This study utilized a validated scale for the primary outcome and also used validated tools for some of the secondary outcomes. Another strength of this study is that it included patients admitted to both free-standing children’s hospitals and community hospitals, thus contributing to greater generalizability for various inpatient practice settings.
Limitations/Flaws: Certain patients were excluded from this study, which limits generalizability for those specific populations. Excluded patients included those with a history of certain medical conditions (chronic lung disease, complex or hemodynamically significant heart disease, immunodeficiency, or neuromuscular disease), the need for continued narcotic or benzodiazepine wean at the time of hospital discharge, or the need for home oxygen therapy. Other limitations included the lack of standardization of the follow-up visit and the possible introduction of bias given the open-label trial design. The authors also noted that their study was not powered to detect some of the possible benefits of scheduled follow-up, such as earlier recognition of respiratory compromise. Additionally, PCP perspectives on scheduled versus as-needed follow-up visits were not obtained.
Takeaway Message: With regards to reducing parental anxiety, as-needed PCP follow-up visits were non-inferior to scheduled PCP follow-up visits in otherwise healthy children discharged from the hospital after admission for bronchiolitis. Also, there was no significant difference in hospital readmissions or ED visits between the two groups.
Practice Impact: Hospital providers may recommend as-needed PCP follow-up for children who were admitted for bronchiolitis and who do not have significant medical comorbidities.