International variation in evidence-based emergency department management of bronchiolitis: a retrospective cohort study

Lirette, Marie-Pier; Kuppermann, Nathan; Finkelstein, Yaron; Zemek, Roger; Plint, Amy C; Florin, Todd Adam; Babl, Franz E.; Dalziel, Stuart; Freedman, Stephen; Roland, Damian; Lyttle, Mark David; Schnadower, David; Steele, Dale; Fernandes, Ricardo M; Stephens, Derek; Kharbanda, Anupam; Johnson, David W; Macias, Charles; Benito, Javier; Schuh, Suzanne

Abstract

OBJECTIVES: We aimed to evaluate the international variation in the use of evidence-based management (EBM) in bronchiolitis. We hypothesised that management consistent with full-EBM practices is associated with the research network of care, adjusted for patient-level characteristics. Secondary objectives were to determine the association between full-EBM and (1) hospitalisation and (2) emergency department (ED) revisits resulting in hospitalisation within 21 days. DESIGN: A secondary analysis of a retrospective cohort study. SETTING: 38 paediatric EDs belonging to the Paediatric Emergency Research Network in Canada, USA, Australia/New Zealand UK/Ireland and Spain/Portugal. PATIENTS: Otherwise healthy infants 2-11 months old diagnosed with bronchiolitis between 1 January 2013 and 31 December, 2013. OUTCOME MEASURES: Primary outcome was management consistent with full-EBM, that is, no bronchodilators/corticosteroids/antibiotics, no chest radiography or laboratory testing. Secondary outcomes included hospitalisations during the index and subsequent ED visits. RESULTS: 1137/2356 (48.3%) infants received full-EBM (ranging from 13.2% in Spain/Portugal to 72.3% in UK/Ireland). Compared with the UK/Ireland, the adjusted ORs (aOR) of full-EBM receipt were lower in Spain/Portugal (aOR 0.08, 95% CI 0.02 to 0.29), Canada (aOR 0.13 (95% CI 0.06 to 0.31) and USA (aOR 0.16 (95% CI 0.07 to 0.35). EBM was less likely in infants with dehydration (aOR 0.49 (95% CI 0.33 to 0.71)), chest retractions (aOR 0.69 (95% CI 0.52 to 0.91)) and nasal flaring (aOR 0.69 (95% CI 0.52 to 0.92)). EBM was associated with reduced odds of hospitalisation at the index visit (aOR 0.77 (95% CI 0.60 to 0.98)) but not at revisits (aOR 1.17 (95% CI 0.74 to 1.85)). CONCLUSIONS: Infants with bronchiolitis frequently do not receive full-EBM ED management, particularly those outside of the UK/Ireland. Furthermore, there is marked variation in full-EBM between paediatric emergency networks, and full-EBM delivery is associated with lower likelihood of hospitalisation. Given the global bronchiolitis burden, international ED-focused deimplementation of non-indicated interventions to enhance EBM is needed.

Citation

Lirette, M., Kuppermann, N., Finkelstein, Y., Zemek, R., Plint, A. C., Florin, T. A., …Schuh, S. (2022). International variation in evidence-based emergency department management of bronchiolitis: a retrospective cohort study. BMJ Open, 12(12), e059784. https://doi.org/10.1136/bmjopen-2021-059784

• Journal Article Type: Article
• Acceptance Date: Feb 2, 2022
• Online Publication Date: Dec 7, 2022
• Publication Date: Dec 7, 2022
• Deposit Date: Dec 28, 2022
• Publicly Available Date: Jan 3, 2023
• Journal: BMJ Open
• Electronic ISSN: 2044-6055
• Publisher: BMJ Publishing Group
• Peer Reviewed: Peer Reviewed
• Volume: 12
• Issue: 12
• Pages: e059784
• DOI: https://doi.org/10.1136/bmjopen-2021-059784
• Keywords: Emergency medicine, 1506, 1691, PAEDIATRICS, Paediatric A&E and ambulatory care, Paediatric infectious disease & immunisation
• Public URL: https://uwe-repository.worktribe.com/output/10256683
• Publisher URL: https://bmjopen.bmj.com/content/12/12/e059784
• Additional Information: Data are available on reasonable request. Data are available on reasonable request. Deidentified patient data are available from Derek Stephens at [e-mail] to researchers with funded study protocol whose proposed use of the data has been approved for a specific purpose, with a signed data access agreement.