Improving Pediatric Respiratory Chest Radiograph Stewardship in a Statewide Network

OBJECTIVE: To investigate the impact of a multicomponent quality improvement (QI) and financial incentive program on chest radiograph (CXR) stewardship in children with asthma, bronchiolitis, and croup in a statewide emergency network. METHODS: The Michigan Emergency Department Improvement Collaborative launched a multicomponent QI program in March 2019 to decrease routine CXR use in children with common respiratory conditions. A subset of sites elected to adopt this CXR use metric within a financial incentive program. We analyzed data from visits between May 2017 and April 2023 at 39 emergency departments (EDs). The primary outcome was overall CXR use as a proportion of ED visits for asthma, bronchiolitis, and croup. We aggregated performance monthly at the site level and used statistical process control charts to assess improvement trends. Changes in ED revisits for respiratory conditions within 72 hours and admission rates served as balancing measures. RESULTS: A total of 114 238 respiratory visits were included. Network-wide CXR use decreased from 34.3% of all ED respiratory visits at baseline to 21.1%. In sites selecting CXR use as an incentive measure, CXR use decreased from 32.5% to 19.2%. Rates of ED revisits for respiratory conditions did not change from the pre- to postintervention period (3.4% vs 3.6%, P = .22), while admission rates increased only modestly (21.5% vs 22.5%, P < .001). CONCLUSION: ED use of CXR in children with common respiratory conditions decreased statewide after implementation of a multicomponent QI initiative and incentive program, providing a potential framework for improvement in other health care systems.