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

Alisha Jamal; Yaron Finkelstein; Nathan Kuppermann; Stephen B Freedman; Todd A Florin; Franz E Babl; Stuart R Dalziel; Roger Zemek; Amy C Plint; Dale W Steele; David Schnadower; David W Johnson; Derek Stephens; Anupam Kharbanda; Damian Roland; Mark D Lyttle; Charles G Macias; Ricardo M Fernandes; Javier Benito; Suzanne Schuh; Pediatric Emergency Research Networks

doi:10.1016/S2352-4642(19)30193-2

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

Lancet Child Adolesc Health. 2019 Aug;3(8):539-547. doi: 10.1016/S2352-4642(19)30193-2. Epub 2019 Jun 7.

Authors

Alisha Jamal¹, Yaron Finkelstein², Nathan Kuppermann³, Stephen B Freedman⁴, Todd A Florin⁵, Franz E Babl⁶, Stuart R Dalziel⁷, Roger Zemek⁸, Amy C Plint⁸, Dale W Steele⁹, David Schnadower¹⁰, David W Johnson¹¹, Derek Stephens¹², Anupam Kharbanda¹³, Damian Roland¹⁴, Mark D Lyttle¹⁵, Charles G Macias¹⁶, Ricardo M Fernandes¹⁷, Javier Benito¹⁸, Suzanne Schuh¹⁹; Pediatric Emergency Research Networks

Affiliations

¹ Division of Pediatric Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
² Division of Pediatric Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; Research Institute, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
³ Department of Emergency Medicine and Department of Pediatrics, UC Davis School of Medicine, University of California, Sacramento, CA, USA.
⁴ Section of Pediatric Emergency Medicine and Section of Gastroenterology, Department of Pediatrics, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
⁵ Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Division of Emergency Medicine, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA.
⁶ Emergency Department, Royal Children's Hospital, Murdoch Children's Research Institute, University of Melbourne, Melbourne, VIC, Australia.
⁷ Emergency Department, Starship Children's Hospital, Auckland, New Zealand; Department of Surgery and Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.
⁸ Division of Pediatric Emergency Medicine, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, ON, Canada.
⁹ Pediatric Emergency Medicine, Hasbro Children's Hospital, Providence, RI, USA; Department of Emergency Medicine, Department of Pediatrics, and Department of Health Services, Policy, and Practice, Brown University, Providence, RI, USA.
¹⁰ Division of Pediatric Emergency Medicine, Washington University School of Medicine, St Louis, MO, USA.
¹¹ Section of Pediatric Emergency Medicine and Section of Gastroenterology, Department of Pediatrics, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Emergency Medicine, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Physiology and Pharmacology, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
¹² Research Institute, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
¹³ Department of Pediatric Emergency Medicine, Children's Hospital of Minnesota, Minneapolis, MN, USA.
¹⁴ Paediatric Emergency Medicine Leicester Academic Group, Leicester Royal Infirmary, Leicester, UK; SAPPHIRE Group, Department of Health Sciences, University of Leicester, Leicester, UK.
¹⁵ Emergency Department, Bristol Royal Hospital for Children, Bristol, UK; Faculty of Health and Applied Life Sciences, University of the West of England, Bristol, UK.
¹⁶ Pediatric Emergency Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.
¹⁷ Department of Paediatrics, Hospital de Santa Maria and Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal.
¹⁸ Paediatric Emergency Department, Cruces University Hospital, Barakaldo, Spain.
¹⁹ Division of Pediatric Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; Research Institute, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada. Electronic address: suzanne.schuh@sickkids.ca.

PMID: 31182422
DOI: 10.1016/S2352-4642(19)30193-2

Abstract

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.

Publication types

Multicenter Study
Research Support, Non-U.S. Gov't

MeSH terms

Adrenal Cortex Hormones / therapeutic use*
Albuterol / therapeutic use*
Bronchiolitis / drug therapy*
Bronchodilator Agents / therapeutic use*
Emergency Service, Hospital*
Humans
Infant
Patient Discharge
Practice Patterns, Physicians'*
Retrospective Studies

Substances

Adrenal Cortex Hormones
Bronchodilator Agents
Albuterol