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.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 539-547 |
| Number of pages | 9 |
| Journal | The Lancet Child and Adolescent Health |
| Volume | 3 |
| Issue number | 8 |
| DOIs | |
| State | Published - Aug 2019 |
Funding
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 guidelines 3–12 because there is little evidence of them having any benefit, 14,26,28,29,35–39 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.
ASJC Scopus subject areas
- Pediatrics, Perinatology, and Child Health
- Developmental and Educational Psychology