Barriers to Reducing Subthreshold Phototherapy for Neonatal Jaundice

OBJECTIVE In a national, multicenter quality improvement (QI) collaborative to reduce subthreshold inpatient phototherapy, the proportion of subthreshold encounters was high at baseline and remained high after the intervention period. This study aimed to assess why clinicians start subthreshold phototherapy and the barriers to reducing its use. METHODS This convergent mixed methods study used data from the Learning and Implementing Guidelines for Hyperbilirubinemia Treatment QI collaborative. Site leaders were asked 2 open-ended questions on why clinicians start phototherapy below threshold and what the biggest barriers were to changing clinician hyperbilirubinemia practice. Themes from these responses informed the variables selected for the quantitative analysis. For each variable, we used F-tests to assess for associations with changes in mean subthreshold phototherapy from the baseline (2/2022-7/2022) to intervention period (2/2023-1/2024). RESULTS We identified 6 themes for subthreshold phototherapy use and 6 for barriers of change. Themes identified for both included lack of timely outpatient follow-up, concerns for prolonging birth hospitalizations and/or causing readmissions, and clinician habit and discomfort with change and higher total serum bilirubin levels. Quantitatively, despite the reported challenges with follow-up, access to weekend bilirubin follow-up or home phototherapy were not associated with statistically significant reductions in subthreshold phototherapy, nor was implementation of clinical pathways to standardize care and discourage subthreshold phototherapy. CONCLUSION Our results suggest that clinician decisions to start subthreshold phototherapy are complex and ineffectively addressed by traditional QI interventions. Deeper exploration of barriers and alternative interventions may be needed in future QI work.