LAUSR

Outside of being born, viral bronchiolitis is the most common reason for a child to be hospitalized in the US, and among the costliest from the US health care system perspective. Given the prevalence of the condition, any regularly employed low-value care practice can quickly add up. Using continuous pulse oximetry for noncritically ill children hospitalized due to bronchiolitis is often cited as an example given the self-resolving oxygen desaturations that frequently occur in this condition. In this issue of JAMA Network Open, Moretti et al1 present the results of an economic evaluation for the use of continuous pulse oximetry for children hospitalized with bronchiolitis in 6 Canadian hospitals. This cost-effectiveness analysis was conducted alongside a 2021 randomized clinical trial2 and included children hospitalized with stabilized bronchiolitis who were enrolled and randomized to either receive continuous or intermittent oximetry monitoring during their hospital stay. Clinical outcomes for patients, including length of stay and revisits after discharge, were followed prospectively. The authors appropriately adopted a health care system and an expanded societal perspective that accounted for broader value elements such as lost productivity and out-of-pocket costs for families. Presenting both perspectives is important and shows the relative value of intermittent oximetry monitoring compared with continuous pulse oximetry based on different viewpoints.3 According to the results from both perspectives, which accounted for the parameter uncertainty through probabilistic sensitivity analysis, the authors found no substantial difference in costs between the intermittent and continuous pulse oximetry monitoring strategies for children with stabilized bronchiolitis. Having randomized trial data and a rigorous economic evaluation for a common condition like bronchiolitis is an overdue change of pace in pediatrics, where the evidence underpinning practices relies on a preponderance of observational data and where cost-effectiveness data accounting for family spillover effects are limited. The results from this study bring up several points for further discussion. First, as the authors point out, the Canadian global health care system is unique, and the health care system findings might be less applicable to the US health care system. Based on this, the policy implications for children hospitalized in the US remain uncertain, and it is implausible that a single study will change current clinical practice. For instance, given the wide confidence intervals in the current study, we may expect even more uncertainty in the context of a less standardized system with multiple payors in the US. Second, micro-costing for nurse or respiratory therapist time assessing patients and responding to pulse oximetry monitor alarms, which are numerous but infrequently actionable, was not available for this study. In addition to the direct nursing care hours needed to review and respond to monitor alarms, the likelihood that essential nursing care is left undone due to unnecessary monitoring-related interruptions is high and difficult to financially quantify.4 Future studies should strongly consider the value to the health care system of understanding the person-time involved in interventions like continuous monitoring, especially in view of the current crises the US health care system related to professional nursing shortages. There have been recent national efforts to address continuous pulse oximetry overuse for bronchiolitis, including an active multicenter deimplementation trial,5 and the most recent update of the bronchiolitis care practice guidelines from the American Academy of Pediatrics made clear that continuous pulse oximetry is an optional part of patient care based on a number of known detrimental effects of related to its use. Of paramount importance to patient safety include the wellknown issue of alarm fatigue and the also well-known (although maybe less discussed) practical aspects of pulse oximetry like young kids getting completely tangled up in wires or the small but real + Related article