- Design
- Convergent mixed-methods study within a national QI collaborative
- Population
- US hospitals in a neonatal hyperbilirubinaemia QI collaborative
- Primary outcome
- Reasons for and barriers to reducing subthreshold phototherapy
- Effect
- Weekend follow-up, home phototherapy and pathways not associated with significant reduction
A US national quality-improvement collaborative set out to reduce phototherapy started below guideline thresholds in newborns. The share of subthreshold treatment was high at baseline and stayed high. This mixed-methods study asked site leaders why.
The recurring reasons were lack of timely outpatient follow-up, worry about prolonging the birth admission or causing readmission, and clinician habit and discomfort with higher bilirubin levels. Yet sites that offered weekend bilirubin checks or home phototherapy, or introduced clinical pathways, did not reduce subthreshold treatment significantly.
The lesson is that the stated reason is not always the operative one. Clinicians treat below threshold partly because it feels safer, and system fixes alone did not change that.
- Plot every bilirubin on the threshold chart for the infant's gestation and risk factors before starting phototherapy.
- Unnecessary phototherapy separates mother and baby and can disrupt breastfeeding.
- Arrange reliable follow-up bilirubin checks rather than treating early to avoid them.
- Discuss threshold-based care openly in the team; habit was a major driver.
Why it matters
Pathways and better follow-up did not change behaviour, which suggests the barrier is clinician comfort, not logistics.
Don't overread it
Site-level associations from a small number of sites; the lack of effect may reflect limited power.
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