Articles
Pharmacotherapy in bronchiolitis at discharge from emergency departments within the Pediatric Emergency Research Networks: a retrospective analysis

https://doi.org/10.1016/S2352-4642(19)30193-2Get rights and content

Summary

Background

Clinical guidelines advise against pharmacotherapy in bronchiolitis. However, little is known about global variation in prescribing practices for bronchiolitis at discharge from emergency departments. We aimed to evaluate global variation in prescribing practice (ie, inhaled salbutamol, or oral or inhaled corticosteroids) for infants with bronchiolitis at discharge from emergency departments.

Methods

We did a planned secondary analysis of a multinational, retrospective cohort study of the Pediatric Emergency Research Networks. Previously healthy infants (aged <12 months) who were discharged with bronchiolitis between Jan 1 and Dec 31, 2013 from 38 emergency departments in Australia and New Zealand, Canada, Spain and Portugal, the UK and Ireland, and the USA were included. The primary outcome was pharmacotherapy prescription at discharge from the emergency department. Secondary outcomes were revisits to the emergency department or hospitalisations for bronchiolitis within 21 days of discharge.

Findings

Of 1566 infants discharged from the emergency department, 317 (20%) were prescribed pharmacotherapy. Corticosteroid prescriptions were infrequent, ranging from 0% (0 of 68 infants) in Spain and Portugal to 6% (25 of 452) in the USA. Salbutamol prescriptions ranged from 5% (22 of 432) in the UK and Ireland to 32% (146 of 452) in the USA. Compared with the UK and Ireland, the odds of prescription of pharmacotherapy were increased in Spain and Portugal (odds ratio [OR] 9·22, 95% CI 1·70–49·96), the USA (8·20, 2·79–24·11), Canada (5·17, 1·61–16·67), and Australia and New Zealand (1·21, 0·36–4·10). After adjustment for clustering by site, pharmacotherapy at discharge was associated with older age (per 1 month increase; OR 1·23, 95% CI 1·16–1·30), oxygen saturation (per 1% decrease from 100%; 1·09, 1·01–1·18), chest retractions (1·88, 1·26–2·79), network (p=0·00050), and site (p<0·00090). 303 (19%) of 1566 infants returned to the emergency department and 129 (43%) of 303 were hospitalised. Discharge pharmacotherapy was not associated with revisits (p=0·55) or subsequent hospitalisations (p=0·50).

Interpretation

Use of ineffective medications in infants with bronchiolitis at discharge from emergency departments is common, with large differences in prescribing practices between countries and emergency departments. Enhanced knowledge translation and deprescribing efforts are needed to optimise and unify the management of bronchiolitis.

Funding

None.

Introduction

Bronchiolitis is the leading cause of infant hospitalisation in the USA and other high-income countries.1, 2 The use of pharmacotherapy has not been shown to improve bronchiolitis outcomes, prompting professional societies around the world to advise against its routine use.3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 However, the impact of international bronchiolitis practice guidelines on unwarranted use of resources continues to be suboptimal.14, 15, 16, 17, 18 The use of resources in bronchiolitis varies substantially between countries and regions. In places where the use of resources persists, such as in North America, it is associated with major costs.8, 9, 11, 14, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28

Previous studies have examined the use of pharmacotherapy for bronchiolitis in emergency department and inpatient settings.14, 15, 19, 20, 21, 22, 26, 29, 30 However, studies of pharmacotherapies specifically prescribed at discharge from medical encounters have focused on community hospitals,31 hospitalised children,32, 33 and non-hospital-based ambulatory practices.34 A 2017 study reported that children with bronchiolitis often receive non-evidence-based interventions while in the emergency department,25 but little is known about prescribing practices at discharge from the emergency department.

To address this knowledge gap, we did a planned secondary analysis of a multicentre, multinational, retrospective cohort study of previously healthy infants with bronchiolitis who presented to any of the emergency departments associated with the Pediatric Emergency Research Networks—five national, research-focused groups of paediatric emergency departments in Australia and New Zealand, Canada, Spain and Portugal, the UK and Ireland, and the USA. The primary objective was to evaluate variation across research networks in the proportion of infants who were prescribed either inhaled bronchodilators, or systemic or inhaled corticosteroids, for home use when they were discharged from the emergency department. Although such prescriptions are discouraged by clinical practice guidelines3, 4, 5, 6, 7, 8, 9, 10, 11, 12 because there is little evidence of them having any benefit,14, 26, 28, 29, 35, 36, 37, 38, 39 we believe these medications are commonly prescribed. A 2017 investigation, funded by the US National Institutes of Health, highlighted the paucity of de-implementation efforts in the USA,40 and the North American Choosing Wisely initiative aims to systematically improve the value of health care by reducing the use of ineffective therapies.41 Our study provides background data for future de-implementation efforts to unify prescription practices and decrease the costs of care for this common disease. We hypothesised that that there would be a significant association between prescription for pharmacotherapy at discharge from the emergency department and the network to which the infant presented, after adjustment for patient-level characteristics. Secondary objectives were to examine associations between prescriptions for pharmacotherapies at emergency department discharge and subsequent return visits to the emergency department and hospitalisations for bronchiolitis.

Research in context

Evidence before this study

Bronchiolitis is a common illness in infancy and the leading cause of infant hospitalisation in high-income countries. Previous studies suggest that pharmacotherapy does not change the clinical course of bronchiolitis, and its use has been discouraged by professional societies worldwide. However, many clinicians continue to administer medications to infants with bronchiolitis, with marked variation in international practices and substantial health-care costs. Although infants with bronchiolitis seeking care in emergency departments often receive non-recommended pharmacotherapy while in the emergency department, little is known about prescription practices for non-recommended medications at discharge from the emergency department. On June 28, 2018, we did a search of PubMed, MEDLINE, and Embase for publications in English using the following search terms: “bronchiolitis/viral bronchiolitis” plus “bronchodilators” or “corticosteroids” plus “patient discharge” or “hospital/emergency discharge”, “patient re-admission/re-hospitalisation”, and “infant”. We found four articles on the use of pharmacotherapy for bronchiolitis at discharge from medical encounters. However, these studies focused on hospitalised infants, community emergency departments, and outpatient clinics, and none examined the use of pharmacotherapy at discharge in more than one country. A further 11 articles described the use of pharmacotherapy in the emergency department or an inpatient setting. We found no studies of bronchiolitis that reported the use of bronchodilators or corticosteroids at discharge from paediatric emergency departments at an international level.

Added value of this study

This multinational study provides a comprehensive assessment of the variation in pharmacological management of acute bronchiolitis in infants discharged from the emergency department across five national research networks in eight countries. To the best of our knowledge, this is the first study to compare emergency department discharge treatment practices of infant bronchiolitis globally, with use of all available data from established collaborative ED networks. Our findings will inform future global practice to deprescribe non-effective medications for bronchiolitis and de-implement the use of non-recommended interventions, in an effort to unify and improve standards and decrease the cost of care of infants with bronchiolitis. Reduced use of pharmacotherapy at discharge from the emergency department in bronchiolitis would also decrease the potential for treatment-related adverse events and minimise parental expectations of benefit from non-indicated medications.

Implications of all the available evidence

The continued use of ineffective treatments for bronchiolitis emphasises the need for enhanced knowledge translation and de-implementation efforts to optimise and unify disease management. Further research into supportive bronchiolitis management strategies, such as clarifying the benefit of non-pharmacological therapies, might also be beneficial.

Section snippets

Study design and participants

We did a retrospective cohort study at 38 paediatric emergency departments in eight countries, all of which are member sites of the Pediatric Emergency Research Networks.42 The Pediatric Emergency Research Networks are an international collaboration comprising five national or regional networks: Pediatric Emergency Research Canada; Pediatric Emergency Medicine Collaborative Research Committee (PEM-CRC) and Pediatric Emergency Care Applied Research Network (PECARN) in the USA; Paediatric

Results

5305 potentially eligible infants were identified across the 38 sites between Jan 1, and Dec 31, 2013. 1580 of them met exclusion criteria. Among the remaining 3725 eligible patients, 1466 (39%) were admitted to hospital and 2259 (61%) were discharged home. The hospitalisation rate from the emergency department varied between 30% (in Spain and Portugal) and 46% (in Australia and New Zealand).25

1566 (69%) of 2259 discharged infants had full data on all study variables and were included in this

Discussion

This large, international study of infants diagnosed with bronchiolitis, which was done in 38 paediatric emergency departments from six national or regional research networks, shows substantial inter-network and inter-site variation in the use of prescriptions for bronchodilators and corticosteroids at discharge from the emergency department. Prescribing practices do not appear to be associated with subsequent bronchiolitis-related emergency department revisits and hospitalisations. Most

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