National Current Care Guidelines for paediatric lower respiratory tract infections reduced the use of chest radiographs but local variations were observed

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(1)UEF//eRepository DSpace Rinnakkaistallenteet. https://erepo.uef.fi Terveystieteiden tiedekunta. 2021. National Current Care Guidelines for paediatric lower respiratory tract infections reduced the use of chest radiographs but local variations were observed Poutanen, Roope Wiley Tieteelliset aikakauslehtiartikkelit © 2020 Foundation Acta Pædiatrica All rights reserved http://dx.doi.org/10.1111/apa.15692 https://erepo.uef.fi/handle/123456789/24433 Downloaded from University of Eastern Finland's eRepository.

(2) Accepted Article. DR. ROOPE POUTANEN (Orcid ID : 0000-0003-2951-3777) DR. PAULA HEIKKILÄ (Orcid ID : 0000-0002-5989-8615) DR. SATU-LIISA PAUNIAHO (Orcid ID : 0000-0002-8212-9240) DR. PETER CSONKA (Orcid ID : 0000-0003-0819-7875) PROF. MATTI KORPPI (Orcid ID : 0000-0001-8153-1919) DR. MARJO RENKO (Orcid ID : 0000-0003-0507-4773). Article type. : Regular Article. National Current Care Guidelines for paediatric lower respiratory tract infections reduced the use of chest radiographs but local variations were observed Roope Poutanen1,2, Tuija Virta2, Paula Heikkilä1,2, Satu-Liisa Pauniaho1, Peter Csonka1,4, Matti. Korppi1, Marjo Renko3 and Sauli Palmu1,2. 1. Centre for Child Health Research, Tampere University and Department of Pediatrics, Tampere. University Hospital, Tampere, Finland 2. Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland. 3. Department of Paediatrics, Kuopio University Hospital, University of Eastern Finland, Kuopio,. Finland 4. Terveystalo Healthcare, Tampere, Finland.. Running title: National guidelines and chest radiographs Address for correspondence: Roope Poutanen, MD Tampere Centre for Child Health Research, Arvo Ylpönkatu 34, FI-33014 University of Tampere, FINLAND This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/APA.15692 This article is protected by copyright. All rights reserved.

(3) Accepted Article. Email: roope.poutanen@tuni.fi Tel: +358405716003 Abstract 200 words, key notes 69 words, text 3053 words, 27 references, 4 tables, 1 supplementary table. This article is protected by copyright. All rights reserved.

(4) Accepted Article. ABSTRACT Aim. Our aim was to evaluate the impact of the 2014 Finnish Current Care Guidelines for paediatric lower respiratory tract infections (LRTIs), particularly on taking of chest radiographs. Methods This study used official national data and regional (Pirkanmaa) data on children aged 0-16 years who underwent chest radiographs in 2011 and 2015. We also collected data for LRTI diagnoses from local registers, including prescribed antibiotics and taking of chest radiographs. The local cohort comprised children aged 0-15 who presented to the primary care emergency room or to the hospital emergency department (Tampere university hospital) in November-December 2012-2015. Results. Chest radiographs for Finnish children aged 0-16 fell from 2011 to 2015: by 15.9% nationally and by 16.9% in Pirkanmaa. When asylum seekers with chest radiographs for tuberculosis screening were excluded, the estimated national reduction was 29.9%. In the local cohort chest radiographs increased from 82 to 139 (69.5%) between 2012/2013 and 2014/2015 as the occurrence of community acquired pneumonia (CAP) increased. However, the proportion of patients with CAP who had chest radiograph taken tended to decrease from 84.6% to 71.3% (p=0.078). Conclusion Decreases in national and regional chest imaging trends were observed after the 2014 guidance for children`s LRTI was introduced. KEY WORDS Antibiotics, chest radiographs, care guidelines, community-acquired pneumonia, lower respiratory tract infections. KEY NOTES . This study evaluated whether the 2014 Finnish Current Care Guidelines for paediatric lower respiratory tract infections had an impact on chest imaging in children.. . Overall, nationally chest radiographs fell by 15.9% and they fell by 16.9% in the Pirkanmaa region.. This article is protected by copyright. All rights reserved.

(5) However, they increased by 69.5% in our local primary care emergency room and. Accepted Article. . university hospital emergency department, mainly due to high rates of communityacquired pneumonia treated in these units.. INTRODUCTION Lower respiratory tract infections (LRTIs), such as pneumonia, are major reasons why children visit doctors or are admitted to hospitals worldwide. The mortality rate for LRTIs, including community-acquired pneumonia (CAP), is low in developed countries. However, these infections create a substantial burden for children, families and societies in terms of decreased quality of life, costs and lost working days (1,2). Chest radiographs have long been considered the gold standard for diagnosing pneumonia, but the current international guidelines recommend that CAP diagnoses should be mainly based on clinical signs and symptoms (3,4). Chest imaging is recommended for severe cases requiring hospitalisation and when complications, such as empyema, are suspected. Active use of chest radiographs for children with LRTIs may lead to over-diagnosing pneumonia and prescribing unnecessary antibiotics (5). The Finnish Current Care Guidelines on the diagnosis and treatment of LRTIs in children were published in June 2014 (6,7). These guidelines are in agreement with the paediatric pneumonia guidelines produced by the British Thoracic Society (4) and the Infectious Disease Society of America (3). All three guidelines advise clinicians to avoid chest imaging if children have LRTI with an uncomplicated course (3,4,6,7). In general, studies on the impact of medical guidelines have produced controversial results (8). Some studies have confirmed that guidelines have led to reductions in chest imaging in infant bronchiolitis (9) and paediatric asthma (10,11). However, such effects are difficult to prove true or rule out. Other studies have highlighted the diagnostic value of chest radiographs for children with pneumonia (12–16). One study showed an association between taking more images and. This article is protected by copyright. All rights reserved.

(6) Accepted Article. prescribing more antibiotics (5), while another found that more images resulted in fewer antibiotics (17). Only a few studies have specifically evaluated whether clinicians followed recommendations not to take chest radiographs if they suspected the child had pneumonia (18–20). It has already been demonstrated that the Finnish 2014 guidelines for LRTIs in children decreased the use of racemic adrenaline in bronchiolitis (21). The aim of this study was to evaluate the impact of the Finnish Current Care Guidelines for paediatric LRTIs, published in June 2014, on taking chest radiographs when children had LRTI, especially diagnosed or suspected CAP. First, we compared the national Finnish figures for chest radiographs taken in 2011 and 2015, with specific reference to the different age groups and the figures for our region. Second, we evaluated how many chest radiographs were taken by two local outpatient clinics: the primary care emergency room in the healthcare centre and the secondary care emergency department in the university hospital. These data were then analysed in relation to the child’s age, the clinical diagnosis and the emergency clinic the children visited. MATERIALS AND METHODS National and regional data We collected the national data on the numbers of chest radiographs performed in Finnish children, including data for the Pirkanmaa region, where our university hospital is based. The source of this data was the Finnish Radiation and Nuclear Safety Authority, which collects national data on all radiological examinations carried out in Finland. The Authority publishes its statistics every three to four years. The most relevant reports for our study period were the years 2011 and 2015, which were before and after the publication of the Finnish Current Care Guidelines for children’s LRTIs in 2014. The Authority provides the data separately for examinations carried out inside and outside radiological units and splits the data into four age groups: 0-23 months, 2-6 years, 7-12 years and 13-16 years. No data are registered on the indications for or the findings of radiological studies.. For the national and regional data, we excluded the examinations that were performed outside radiology units, because the vast majority of these were carried out in neonatology or haemato-. This article is protected by copyright. All rights reserved.

(7) Accepted Article. oncology units for indications that fell outside the scope of this study. In Finland, all immigrants coming from high-risk tuberculosis countries are screened with chest radiographs. Because of an extraordinary increase in immigration during the year 2015, we estimated the annual numbers of asylum seekers who received chest radiograph. The Finnish Immigration Service provided us with the total numbers of asylum seekers aged 0-17 years for 2011 and 2015. To calculate estimated figures for the 0-16 age group we adjusted the numbers of asylum seekers by dividing the figures by 18 and then multiplying them by 17. Local data We collected local data on the children with LRTIs, including suspicions of CAP, from the electronic records held by the health centre and the university hospital in Tampere, Pirkanmaa region, Southern Finland. The data collection focused on children aged 0-15 years who had visited the health centre’s emergency room or hospital’s emergency department over a period of eight months, namely November and December in 2012, 2013, 2014 and 2015. We chose November and December as the annual surveillance times because of the high prevalence of LRTIs just during those months. The healthcare centre provides services for 62,000 children aged 0-15 years living in the town and nearby areas, and the emergency room has an access to the university hospital’s imaging and laboratory facilities. Most of the children who attend are seen by general practitioners. Doctors working in the emergency room can consult the hospital’s paediatricians by phone if they need to. The children who attend the emergency room are either discharged and treated at home or admitted to the emergency department of the hospital. This secondary care emergency department is staffed by paediatricians and paediatric residents and provides services for around 90,000 children aged 0-15 years living in the region. The children who attend the emergency department are either discharged and treated at home or admitted to a hospital ward. Child populations for which the emergency department and emergency room are responsible, overlap considerably. We included patients in primary healthcare centre’s emergency room or the hospital’s emergency department with the following International Classification of Diseases, Tenth Revision (ICD-10) codes: pneumonia (J18), acute bronchitis (J20) and acute bronchiolitis (J21). Based on ICD-10. This article is protected by copyright. All rights reserved.

(8) Accepted Article. detailed codes children were further classified into four diagnostic groups: community-acquired pneumonia, bronchiolitis, bronchitis without wheezing and bronchitis with wheezing. We analysed the results using four age groups: 0-23 months, 2-4 years, 5-9 years and 10-15 years. The data that were collected consisted of the ICD-10 code, the age at the time of the visit, any medication that was prescribed, and whether a chest radiograph was taken. In this data, no corrections for asylum seekers were needed. The electronic files did not contain specific data on the indications for or the findings of radiological studies. Cost data The costs of the chest radiographs were evaluated using the 2020 prices provided for staff working at the Tampere University Hospital, including the emergency room of the healthcare centre. The unit cost of one chest radiograph was 43 Euros, including also lateral projects if obtained. This was then multiplied by the official national data on the numbers of chest radiographs carried out across Finland and in the Pirkanmaa region. It was also used to calculate the costs for the two local study sites, the primary care emergency room and the hospital emergency department. Statistics The data were analysed with SPSS Statistics for Windows, version 25.0. (IBM Corp, New York, USA). The chi-square test and Fisher’s exact test were used to compare the proportions, as appropriate. Ethics. This study was based on published national data and the local hospital and healthcare centre registers. According to Finnish law, we did not need Ethics Committee approval, as the data were drawn from existing sources and patients were not contacted. The study was carried out with the permission of the Head Doctor of the primary healthcare centre and the Chief Medical Doctor of the University Hospital.. This article is protected by copyright. All rights reserved.

(9) Accepted Article. RESULTS National and regional data The national data showed that the numbers of chest radiographs taken from children aged 0-16 were 47,746 in 2011 and 40,178 in 2015, which were before and after the publication of the Finnish guidelines for paediatric LRTIs in 2014 (Table 1). The respective figures for the Pirkanmaa region were 4,317 and 3,589. Between 2011 and 2015 the numbers of chest radiographs decreased by 15.9% for the whole country and by 16.9% for the Pirkanmaa region. These decreases were seen in all age groups and were most pronounced in those children who were 0-23 months old (Table 1). The reduction in this youngest age group was 38.7% for the whole country and 58.0% for the Pirkanmaa region. The numbers of children aged 0-17 years who applied for asylum in Finland were 801 in 2011 and 7652 in 2015. The adjusted estimates for asylum seekers aged 0-16 years were 757 in 2011 and 7227 in 2015. When these figures were taken into account, the estimates for chest radiographs taken in Finnish children were 46,989 and 32,951, respectively. Thus, the estimated decrease was a maximum of 29.9% from 2011 to 2015. Cost data The nationwide costs of the chest radiographs fell from €2,053,078 in 2011 to €1,727,654 in 2015 (Table 1), which meant a reduction of €325,424. The respective costs in the Pirkanmaa region fell by €31,304 (Table 1). The estimated national costs without radiographs for asylum seekers were €2,020,527 and €1,416,893, respectively, which meant a corrected cost reduction of €603,634. Most of the cost savings came from reduced chest radiographs on children aged 0-23 months: they fell from €481,987 to €295,410 nationally and from €35,776 to €15,007 regionally (Table 1).. Local data According to the local patient data, a total of 433 children were treated for LRTI in the primary healthcare centre’s emergency room or the hospital’s emergency department in NovemberDecember in 2012-2013, before the publication of the Finnish 2014 guidelines. In November-. This article is protected by copyright. All rights reserved.

(10) Accepted Article. December in 2014-2015, the respective figure has risen by 31.4% to 569. The figures increased by 14.2% in the healthcare centre’s emergency room, and by 38.0% in the hospital’s emergency department. The 126 children who were treated as inpatients after they had been assessed by the emergency room or emergency department were excluded from the further analyses: 58 were from the 2012-2013 cohort and 68 from the 2014-2015 cohort. After these 126 exclusions, 876 children were treated as outpatients for LRTIs: 375 before the 2014 guidelines and 501 after the 2014 guidelines for paediatric LRTIs (Table 2). This meant an increase of 33.6%. A total of 221 chest radiographs were taken at 876 patient visits during the four surveillance periods in the two local study sites: 49 chest radiographs on 257 patients (19.1%) in the healthcare centre’s emergency room and 172 chest radiographs on 619 patients (27.8%) in the hospital’s emergency department. Of the 221 radiographs, 82 (21.9%), costing €3,526, were taken before the Finnish 2014 guidelines and 139 (27.7%, p=0.047), costing €5,977, were taken afterwards (Table 2).. When CAP cases were excluded, the proportion of chest radiographs taken for other LRTIs were 39 (12.0%) before the 2014 guidelines and 47 (12.2%) afterwards (Table S1). The respective figures were 43 (84.6%) and 94 (71.3%, p=0.078) for just CAP cases (Table 2). In the youngest 04 years age group, the respective figures for children with CAP were 92.1% before the 2014 guidelines and 73.6% afterwards (p=0.019). No other significant differences were found in the age-specific subgroup analyses. The number of CAP diagnoses in November-December of the four study years was 39 in the primary care emergency room (9 in 2012, 4 in 2013, 14 in 2014 and 12 in 2015). The respective figures for the 265 CAP diagnoses in the secondary care emergency department were 49, 44, 79 and 93 (Table 3). Thus, the numbers of CAP diagnoses were 2.0 times higher in the primary care emergency room and 1.8 times higher in the hospital’s emergency department in 2014-2015 than in 2012-2013. We also compared the 76 children who had received antibiotics for LRTIs with those 137 who had not received (Table 4). This comparison showed that the children were more likely to receive. This article is protected by copyright. All rights reserved.

(11) Accepted Article. antibiotics if they had not had a chest radiograph taken. This increase was statistically significant among patients with wheezing and non-wheezing bronchitis.. DISCUSSION This register-based study evaluated the impact of the 2014 Finnish Current Care Guidelines for children’s LRTIs on taking chest radiographs, by studying national, regional and local data before and after the guidelines were introduced. There were two main results. The first was that the number of chest radiographs performed in Finland decreased by 15.9% between 2011 and 2015, before and after the 2014 guidelines were published. The decrease was even larger (29.9%) when the estimated number of mandatory chest radiographs for tuberculosis screening in child asylum seekers were removed from the analyses. The second was that taking chest radiographs ordered by the emergency room of the local healthcare centre and the emergency department of the hospital increased from 21.9% for all LRTI cases in 2012-2013 to 27.7% in 2014-2015. The respective figures for CAP patients were 84.6% in 2012-2013 and 71.3% in 2014-2015. Chest radiographs were still frequently performed in 2015, even though the national and international guidelines recommended that pneumonia could be diagnosed clinically without any imaging. The national register data included in our study indicated that the impact of the Finnish guidelines on performing chest radiographs showed a similar trend to that seen in the USA after the publication of the Infectious Disease Society of America guidelines for childhood CAP in 2011 (3). An American register study of 9.3 million emergency department visits found a decrease of 21.3% in the overall use of chest radiographs in children from 2008 to 2018 (22). In our present study, the decrease in the total number of chest radiographs in Finland was at least 15.9% and maximally 29.9% from 2011 to 2015. The local patient data showed that chest radiographs for children with CAP decreased from 84.6% in 2012-2013 to 71.3% in 2014-2015. A nation-wide study from the USA reported that the imaging rate for paediatric pneumonia in emergency departments fell from 86.6% to 80.4% between 2008 and 2018 (22). Another American study focused on 220,000 emergency department. This article is protected by copyright. All rights reserved.

(12) Accepted Article. visits for CAP in 32 hospitals during 2008-2014. The chest radiography rate was 85.4% before the publication of the American guidelines in 2011 and 81.1% afterwards (18). However, significant inter-hospital variations were seen in both of these American studies (18,22). We had no information about the inter-hospital variations in taking chest radiographs in Finland. Our local data showed that, even after the 2014 Finnish guidelines were published, chest radiographs were still being obtained in over 70% of CAP cases. In general, adherence to the medical guidelines has varied substantially and the best way to implement scientific evidence in clinical practice is still unclear. Local education programmes often increase adherence to guidelines (8), but previous studies have reported controversial results on the impact of pneumonia guidelines (18,19,20,22). Many factors, in addition to clinical signs and symptoms, can lead to chest imaging. These include lack of clinical experience, lack of time, problems with children returning for further appointments, difficulties in communicating with the parents, demands from parents and fears about complaints and even litigation (23). The national data showed that the direct annual cost reductions from 2011 to 2015, which were achieved by taking less chest radiographs in children with LRTIs by time, ranged from €325,424 (15.9%) to maximum of €600,000 (29.9%) based on our estimate. These high national savings were in line with the cost savings in an American children’s hospital when it followed the national bronchiolitis guidelines that were published in 2011. The mean reduction in total costs in US dollars was $197 per patient from 2007-2010 to 2011-2013, before and after the guidelines were published. The total local cost savings were $196,409 for the 997 patients included (24). The reduction in the number of chest radiographs that were performed was the most significant reason for the total cost savings, but the reduction in laboratory testing and medication also had an effect (24). In addition, a Canadian study reported that avoiding chest radiography when treating bronchiolitis patients generated cost savings without compromising diagnostic accuracy (25). A modelling study also showed that huge potential cost savings of up to US$ 1.16 billion a year could be achieved internationally, if the 2014 World Health Organization guidelines for paediatric pneumonia management were adhered to in 74 countries (26). The association between chest radiography and use of antibiotics has been different in different clinical patient groups in previous studies. In an observational study chest radiographs did not alter. This article is protected by copyright. All rights reserved.

(13) Accepted Article. the use of antibiotics among 103 American children with high suspicion for pneumonia (17). However, among those 1503 in whom clinical suspicion for pneumonia was low, the use of chest radiograph reduced antibiotic use (17), in line with our observations in children with wheezing and non-wheezing bronchitis When 522 South-African children with suspected pneumonia were randomised to have or to not have chest radiograph taken, using radiograph slightly increased the use of antibiotics (5). In children`s CAP, unspecific host response markers such as C-reactive protein or procalcitonin are useful, when combined to clinical and radiological findings, in the decision who requires antibiotics (27). The lack of such data was a shortcoming of the local data of the present study. The main limitation of this study was that the data were retrospectively collected from registers and the cases were identified using the ICD-10 codes recorded by the doctors as part of their clinical routines. In addition, the registers did not contain any data on the indications for or findings of chest radiographs. On the other hand, the information just on whether chest radiographs were taken or not was accurately recorded in the electronic registers. There were some differences in the age-related data sources, as our local data covered children aged 0-15, the national register data covered 0-16 and the asylum seekers´ data needed to be adjusted from 0-17 to 0-16 to provide comparable estimates. Prospective studies would provide more solid data, but awareness of an on-going study could influence how doctors behave, for example how precisely they follow the guidelines. CONCLUSION The total national number of chest radiographs taken for children aged 0-16 in Finland decreased by 15.9% from 2011 to 2015, before and after the 2014 guidelines were introduced. When we excluded asylum seekers who received mandatory chest radiographs for tuberculosis screening, the estimated reduction was 29.9%. The data for our local primary care emergency room and secondary care emergency department showed that chest radiographs increased after the guidelines, mainly because of increased occurrence CAP, but the relative rate of radiographs in children with CAP decreased. ABBREVIATIONS. This article is protected by copyright. All rights reserved.

(14) Accepted Article. CAP, community acquired pneumonia; CI, confidence interval; ICD, international classification of diseases; LRTI, lower respiratory tract infection. FUNDING This study was funded by the Päivikki and Sakari Sohlberg Foundation and the Tuberculosis Foundation of Tampere CONFLICTS OF INTEREST The authors have no conflicts of interest to declare.. REFERENCES. 1.. Ciommo V Di, Russo P, Attanasio E, Liso G Di, Graziani C, Caprino L. Clinical and. economic outcomes of pneumonia in children: a longitudinal observational study in an Italian paediatric hospital. J Eval Clin Pract. 2002;8:341–8.. 2.. Shoham Y, Dagan R, Givon-Lavi N, Liss Z, Shagan T, Zamir O, et al. Community-acquired. pneumonia in children: quantifying the burden on patients and their families including decrease in quality of life. Pediatrics. 2005;115:1213–9.. 3.. Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, et al. The. Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53:25–76.. 4.. Harris M, Clark J, Coote N, Fletcher P, Harnden A, McKean M, et al. British Thoracic. Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax. 2011;66:1–23.. 5.. Swingler GH, Hussey GD, Zwarenstein M. Randomised controlled trial of clinical outcome. after chest radiograph in ambulatory acute lower-respiratory infection in children. Lancet. 1998;351:404–8.. 6.. Tapiainen T, Aittoniemi J, Immonen J, Jylkkä H, Meinander T, Nuolivirta K, et al. Finnish. This article is protected by copyright. All rights reserved.

(15) Accepted Article. guidelines for the treatment of laryngitis, wheezing bronchitis and bronchiolitis in children. Acta Paediatr. 2016;105:44–9.. 7.. Work group set by the Finnish Medical Society Duodecim, Finnish Society of Paediatrics. and Fiunnish Society of General Medicine. Lower respiratory tract infections in children. Current Care Guideline. The Finnish Medical Society Duodecim: 2014. (referred 10.11.2019). Available at: www.kaypahoito.fi. 8.. Grol R, Grimshaw J. From best evidence to best practice: Effective implementation of. change in patients’ care. Lancet. 2003;362:1225–30.. 9.. Breakell R, Thorndyke B, Clennett J, Harkensee C. Reducing unnecessary chest X-rays,. antibiotics and bronchodilators through implementation of the NICE bronchiolitis guideline. Eur J Pediatr. 2018;177:47–51.. 10.. Buckmaster A, Boon R. Reduce the rads: A quality assurance project on reducing. unnecessary chest X‐rays in children with asthma. J Paediatr Child Health. 2005;41:107– 11.. 11.. Gentile NT, Ufberg J, Barnum M, McHugh M, Karras D. Guidelines reduce X-ray and. blood gas utilization in acute asthma. Am J Emerg Med. 2003;21:451–3.. 12.. Levinsky Y, Mimouni FB, Fisher D, Ehrlichman M. Chest radiography of acute paediatric. lower respiratory infections: Experience versus interobserver variation. Acta Paediatr. 2013;102:e310-4. 13.. Neuman MI, Monuteaux MC, Scully KJ, Bachur RG. Prediction of pneumonia in a. pediatric emergency department. Pediatrics. 2011;128:246–53.. 14.. Ben Shimol S, Dagan R, Givon-Lavi N, Tal A, Aviram M, Bar-Ziv J, et al. Evaluation of. the World Health Organization criteria for chest radiographs for pneumonia diagnosis in children. Eur J Pediatr. 2012;171:369–74.. 15.. Courtoy I, Lande AE, Turner RB. Accuracy of radiographic differentiation of bacterial from. nonbacterial pneumonia. Clin Pediatr. 1989;28:261–4.. 16.. Swingler GH, Zwarenstein M. Chest radiograph in acute respiratory infections. Cochrane. Database of Systematic Reviews 2008: CD001268. DOI: 10.1002/14651858. CD001268.pub3.. 17.. Nelson KA, Morrow C, Wingerter SL, Bachur RG, Neuman MI. Impact of chest. radiography on antibiotic treatment for children with suspected pneumonia. Pediatr Emerg Care. 2016;32:514–9.. This article is protected by copyright. All rights reserved.

(16) Parikh K, Hall M, Blaschke AJ, Grijalva CG, Brogan T V., Neuman MI, et al. Aggregate. Accepted Article. 18.. and hospital-level impact of national guidelines on diagnostic resource utilization for children with pneumonia at children’s hospitals. J Hosp Med. 2016;11:317–23.. 19.. Ambroggio L, Mangeot C, Kurowski EM, Graham C, Korn P, Strasser M, et al. Guideline. adoption for community-acquired pneumonia in the outpatient setting. Pediatrics. 2018; 142.. 20.. Alak A, Seabrook JA, Rieder MJ. Variations in the management of pneumonia in pediatric. emergency departments: Compliance with the guidelines. Can J Emerg Med. 2010;12:514– 9.. 21.. Palmu S, Mecklin M, Heikkilä P, Backman K, Peltola V, Renko M, et al. National. treatment guidelines decreased the use of racemic adrenaline for bronchiolitis in four Finnish university hospitals. Acta Paediatr. 2018;107:1966-70. 22.. Geanacopoulos A, Porter J, Monuteaux M, Lipsett S, Neuman M. Trends in chest. radiographs for pneumonia in emergency eepartments. Pediatrics. 2020;145:3.. 23.. Studdert DM, Mello MM, Sage WM, DesRoches CM, Peugh J, Zapert K, et al. Defensive. medicine among high-risk specialist physicians in a volatile malpractice environment. J Am Med Assoc. 2005;293:2609–17.. 24.. Akenroye AT, Baskin MN, Samnaliev M, Stack AM. Impact of a bronchiolitis guideline on. ED resource use and cost: A segmented time-series analysis. Pediatrics. 2014; 133:227–34.. 25.. Yong JHE, Schuh S, Rashidi R, Vanderby S, Lau R, Laporte A, et al. A cost effectiveness. analysis of omitting radiography in diagnosis of acute bronchiolitis. Pediatr Pulmonol. 2009; 44:122–7.. 26.. Zhang S, Incardona B, Qazi SA, Stenberg K, Campbell H, Nair H, et al. Cost-effectiveness. analysis of revised WHO guidelines for management of childhood pneumonia in 74 Countdown countries. J Glob Health. 2017;7:010409.. 27.. Principi N, Esposito S. Biomarkers in Pediatric Community-Acquired Pneumonia. Cost-. effectiveness analysis of revised WHO guidelines for management of childhood pneumonia in 74 Countdown countries. Int J Mol Sci. 2017; 18(2):447.. This article is protected by copyright. All rights reserved.

(17) Accepted Article. Table 1. Numbers of chest radiographs taken in radiological units across Finland in 2011 and 2015, presented by age, and cost savings from 2011 to 2015.. Finland (national data). Pirkanmaa (regional data). 2011. 2015. Change. Savings in. 2011. 2015. Change. Savings. number. number. (%). Euros. number. number. (%). in Euros. 0-23 months. 11,209. 6,870. -38.7. 186,577. 832. 349. -58.0. 20,769. 2-6 years. 13,309. 12,092. -9.1. 52,331. 1,315. 1,290. -1.9. 1,075. 7-12 years. 11,114. 9,940. -10.6. 50,482. 1,046. 943. -9.8. 4,429. 12,114. 11,276. -6.9. 36,034. 1,124. 1,007. -10.5. 5,031. 47,746. 40,178. -15.9. 325,424. 4,317. 3,589. -16.9. 31,304. Age. 13-16 years. All ages. The data were extracted from the Finnish Radiation and Nuclear Safety Authority reports and excluded chest radiographs performed on children in hospital wards. The cost data were based on 2020 Tampere University Hospital prices.. This article is protected by copyright. All rights reserved.

(18) Accepted Article. Table 2. The numbers of chest radiographs taken from children treated as outpatients for LRTIs by the two study sites before and after the publication of the 2014 Finnish Current Care Guidelines for paediatric LRTIs, presented separately for all LRTI cases and for the subgroup of communityacquired pneumonia cases (CAP), both in relation to age.. LRTI cases (N=876) Radiographs/cases (%). Radiographs/cases (%). before the guidelines. after the guidelines. Nov/Dec 2012/2013. Nov/Dec 2014/2015. 0-23 months. 37/241 (15.4%). 50/262 (19.1%). 2-4 years. 32/98 (32.7%). Total 0-4 years. CAP cases (N=182) Radiographs/cases (%). Radiographs/cases (%). before the guidelines. after the guidelines. Nov/Dec 2012/2013. Nov/Dec 2014/2015. 0.259. 11/11 (100%). 26/34 (76.5%). 0.169. 51/151 (33.8%). 0.854. 24/27 (88.9%). 38/53 (71.7%). 0.082. 69/339 (20.4%). 101/413 (24.5%). 0.181. 35/38 (92.1%). 64/87 (73.6%). 0.019. 5-9 years. 6/26 (23.1%). 23/58 (39.7%). 0.140. 2/5 (40.0%). 16/22 (72.7%). 0.295. 10-15 years. 7/10 (70%). 15/30 (50%). 0.464. 6/8 (75.0%). 14/22 (63.6%). 0.682. Total all ages. 82/375 (21.9%). 139/501 (27.7%). 0.047. 43/51 (84.3%). 94/131 (71.8%). 0.078. Age. P value. This article is protected by copyright. All rights reserved. P value.

(19) Accepted Article. Table 3. Numbers of children treated for LRTIs by the two study sites before and after the publication of the 2014 Finnish Current Care Guidelines for LRTIs, presented in relation to the four diagnostic subgroups.. Health centre emergency room. Hospital emergency department. Before the guidelines. After the guidelines. Before the guidelines. After the guidelines. Nov/Dec 2012/2013. Nov/Dec 2014/2015. Nov/Dec 2012/2013. Nov/Dec 2014/2015. 120. 137. 313. 432. 13 (10.8%). 26 (19.0%). 93 (29.7%). 172 (39.8%). 48 (40.0%). 55 (40.1%). 6 (1.9%). 12 (2.8%). Bronchitis with wheezing. 53(44,2%). 47 (34.3%). 198 (63.3%). 195 (45.1%). Bronchiolitis. 6 (5.0%). 9 (6.6%). 16 (5.1%). 53 (12.3%). Diagnosis. Total number treated. Community-acquired pneumonia. Bronchitis with no wheezing. This article is protected by copyright. All rights reserved.

(20) Accepted Article. Table 4. The proportion of children who were treated with antibiotics for LRTIs by the two study sites for the whole study period, presented separately for patients with and without chest radiograph examinations. Patients who received intravenous antibiotics and those with otitis media were excluded.. Diagnosis. Community-acquired. Patients with chest radiography Antibiotics / cases (n=76). Patients without chest radiography %. Antibiotics / cases (n=137). %. p value. 33/38. 86.8%. 117/124. 94.4%. 0.154. 40/92. 43.5%. 15/20. 75.0%. 0.011. Wheezing bronchitis. 3/360. 0.8%. 4/47. 8.5%. 0.004. Bronchiolitis. 0/66. 0.0%. 1/5. 20.0%. 0.070. pneumonia. Bronchitis without wheezing. This article is protected by copyright. All rights reserved.

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