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Rivera-Sepulveda A, Hakim M, Aronson L, Glass TF, Blake K, Alexander K, Schrimshaw EW. A Community-Guided Approach to Bronchiolitis: A Needs Assessment and Illness Perception Study. J Patient Exp 2024; 11:23743735241257384. [PMID: 39050093 PMCID: PMC11268019 DOI: 10.1177/23743735241257384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024] Open
Abstract
The factors influencing caregivers' understanding of pediatric respiratory diseases, such as bronchiolitis, can guide patient care and the acceptability of treatment methods within the healthcare system. This study aims to identify illness perceptions and perform a needs assessment among caregivers of children diagnosed with respiratory diseases. This is a prospective, cross-sectional, questionnaire-driven study of a representative sample of caregivers whose children had an acute respiratory illness. The telephone-administered questionnaire was comprised of (1) demographic items; (2) illness perception questionnaire-revised (IPQ-R); and (3) items about personal barriers, the latter 2 of which employed a 5-point Likert response. Cronbach's alpha (α) was used to measure the internal consistency reliability for each item within the IPQ-R. The Pearson 2-tailed correlation coefficient was used to correlate questionnaire items. We included 75 caregivers whose children have been diagnosed with bronchiolitis (51%), reactive airway disease (RAD) (35%), asthma (33%), and wheezing (44%). We found no significance between the child's diagnosis and the site of recruitment. The most important components of the illness perception were illness coherence (α=0.849), psychological attributions (α=0.903), and barriers to diagnosis (α=0.633). Understanding caregivers' perceptions of respiratory diseases will lead to better treatment acceptance. We must clarify the terms used to define bronchiolitis from viral-induced wheezing, RAD, and the first asthma episode in older infants. Identifying caregivers' gaps in knowledge will help establish a cohesive approach to personalized treatment of respiratory diseases in children and their diagnosis.
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Affiliation(s)
| | - Monica Hakim
- University of Central Florida College of Medicine, Nemours Children's Health Department of Pediatrics, Orlando, FL, USA
| | - Lauren Aronson
- University of Central Florida College of Medicine, Nemours Children's Health Department of Pediatrics, Orlando, FL, USA
| | - Todd F. Glass
- Division of Emergency Medicine and Urgent Care, Nemours Children's Health, Orlando, FL, USA
| | - Kathryn Blake
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health, Jacksonville, FL, USA
| | - Kenneth Alexander
- Division of Infectious Disease, Nemours Children's Health, Orlando, FL, USA
| | - Eric W. Schrimshaw
- University of Central Florida College of Medicine, Nemours Children's Health Department of Pediatrics, Orlando, FL, USA
- Department of Population Health Sciences, University of Central Florida, Orlando, FL, USA
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Poço Miranda S, Rodrigues H, Oliveira S. Acute bronchiolitis: The economic impact of non-compliance with national guidelines. J Healthc Qual Res 2024:S2603-6479(24)00055-1. [PMID: 39013687 DOI: 10.1016/j.jhqr.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 05/29/2024] [Accepted: 06/21/2024] [Indexed: 07/18/2024]
Abstract
INTRODUCTION Acute bronchiolitis is a common reason for admission to the pediatric emergency department. Evidence has shown that most interventions do not change the natural course of the disease. MATERIAL AND METHODS This study aimed to evaluate the economic impact of the non-compliance with the acute bronchiolitis Portuguese national guideline. A retrospective study of pediatric emergency episodes of a Portuguese hospital that had a diagnosis of acute bronchiolitis during 2019, was conducted. RESULTS The sample included 344 emergency episodes. Non-compliance with the guideline occurred in 71.8% of the episodes, mostly due to unjustified treatment. Following guideline in the studied hospital for one year would have resulted in an estimated overall 76.6% cost reduction, with a reduction in mean direct costs per patient of 14.93 €, corresponding to a medium saving of 3.89 € for each patient and a reduction of 11.03 € for the Portuguese National Health Service. Analyzing the unjustified mean direct costs, of these 2.97 € were related to inpatient diagnostic tests and therapeutic and the remaining 11.96 € were related to outpatient therapy. Mean direct costs imputed to the patient for outpatient treatment represented only 3.31 €, therefore most of mean direct costs is paid by the National Health Service. CONCLUSIONS Compliance with guideline would allow the reduction of total estimated costs by about 76.6%, representing a waste of resources, without compromising the quality of care provided. Most of the cost associated with non-compliance with the guideline is justified by outpatient therapy, 67% of which was paid by the National Health Service.
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Affiliation(s)
- S Poço Miranda
- Pediatrics Department, Hospital Santa Luzia, Unidade Local de Saúde do Alto Minho, Viana do Castelo, Portugal; Faculty of Economics, University of Porto, Porto, Portugal.
| | - H Rodrigues
- Pediatrics Department, Hospital Santa Luzia, Unidade Local de Saúde do Alto Minho, Viana do Castelo, Portugal
| | - S Oliveira
- Faculty of Economics, University of Porto, Porto, Portugal
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Porcaro F, Cutrera R, Vittucci AC, Villani A. Bronchiolitis guidelines: what about the Italian situation in a primary care setting? Ital J Pediatr 2023; 49:123. [PMID: 37726761 PMCID: PMC10510229 DOI: 10.1186/s13052-023-01527-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/08/2023] [Indexed: 09/21/2023] Open
Abstract
Acute viral bronchiolitis is the most common cause of hospitalization in children under 12 months of age. The variable clinical presentation and the potential for sudden deterioration of the clinical conditions require a close monitoring by healthcare professionals.In Italy, first access care for children is provided by primary care physicians (PCPs) who often must face to a heterogeneous disease presentation that, in some cases, make the management of patient with bronchiolitis challenging. Consequently, Italian studies report poor adherence to national and international guidelines processed to guide the clinicians in decision making in acute viral bronchiolitis.This paper aims to identify the potential factors contributing to the lack of adherence to the suggested guidelines derived by clear and evidence-based recommendations among primary care physicians operating in an outpatient setting, with a specific focus on the context of Italy. Particularly, we focus on the prescription of medications such as β2-agonists, systemic steroids, and antibiotics which are commonly prescribed by PCPs to address conditions that can mimic bronchiolitis.
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Affiliation(s)
- Federica Porcaro
- Pediatric Pulmonology and Cystic Fibrosis Unit, Bambino Gesù Children's Hospital, IRCCS, piazza di Sant'Onofrio 4, Rome, 00165, Italy.
| | - Renato Cutrera
- Pediatric Pulmonology and Cystic Fibrosis Unit, Bambino Gesù Children's Hospital, IRCCS, piazza di Sant'Onofrio 4, Rome, 00165, Italy
| | - Anna Chiara Vittucci
- Pediatric Unit, Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alberto Villani
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
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Orzołek I, Ambrożej D, Makrinioti H, Zhu Z, Jartti T, Feleszko W. Severe bronchiolitis profiling as the first step towards prevention of asthma. Allergol Immunopathol (Madr) 2023; 51:99-107. [PMID: 37169566 DOI: 10.15586/aei.v51i3.788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 02/07/2023] [Indexed: 05/13/2023]
Abstract
Bronchiolitis is the most common respiratory infection leading to hospitalization and constitutes a significant healthcare burden. The two main viral agents causing bronchiolitis, respiratory syncytial virus (RSV) and rhinovirus (RV), have distinct cytopathic, immune response, and clinical characteristics. Different approaches have been suggested for subtyping bronchiolitis based on viral etiology, atopic status, transcriptome profiles in blood, airway metabolome, lipidomic data, and airway microbiota. The highest risk of asthma at school age has been in a subgroup of bronchiolitis characterized by older age, high prevalence of RV infection, previous breathing problems, and/or eczema. Regarding solely viral etiology, RV-bronchiolitis in infancy has been linked to a nearly three times higher risk of developing asthma than RSV-bronchiolitis. Although treatment with betamimetics and systemic corticosteroids has been found ineffective in bronchiolitis overall, it can be beneficial for infants with severe RV bronchiolitis. Thus, there is a need to develop a more individualized therapeutic approach for bronchiolitis and follow-up strategies for infants at higher risk of asthma in the future perspective.
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Affiliation(s)
- Izabela Orzołek
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Dominika Ambrożej
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Warsaw, Poland
- Doctoral School, Medical University of Warsaw, Warsaw, Poland
| | - Heidi Makrinioti
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Zhaozhong Zhu
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Tuomas Jartti
- PEDEGO Research Unit, University of Oulu, Oulu, Finland
- Department of Pediatrics and Adolescent Medicine, University of Oulu, Oulu, Finland
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Wojciech Feleszko
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Warsaw, Poland;
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Bouchibti S, Maul T, Rivera-Sepulveda A. Comparison Between Physicians' and Nurse Practitioners' Resource Utilization in the Diagnosis and Management of Bronchiolitis in the Pediatric Emergency Department. Pediatr Emerg Care 2022; 38:e1564-e1568. [PMID: 36040473 PMCID: PMC11061880 DOI: 10.1097/pec.0000000000002608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to describe the resource utilization of nurse practitioners (NPs) in the pediatric emergency department (ED) and compare among physicians. METHODS A retrospective cross-sectional study of secondary data analysis in a level 1 academic pediatric trauma center was conducted. Patients were aged 1 to 24 months, evaluated in the ED between January 1, 2014, and November 30, 2018, with a diagnosis of bronchiolitis or wheezing. Data included age group, length of stay, disposition, diagnostic tests (chest radiography [CXR], viral testing, respiratory syncytial virus test), treatment (bronchodilator, corticosteroid, antibiotic), and medical provider (physician, NP, combination of both). Resources were evaluated before (early era) and after (late era) the implementation of an institutional clinical practice guideline.Comparisons between groups were done through χ2, Fisher exact, or Kruskal-Wallis test, as appropriate. RESULTS A total of 5311 cases were treated by a physician (65.3%), an NP (30.3%), or a combination of both (4.3%). The was a difference in the use of CXR, respiratory syncytial virus testing, bronchodilators, and corticosteroids among providers (P = 0.001). In the late era, NPs were less likely to order a bronchodilator (odds ratio [OR], 0.390 [95% confidence interval, 0.318-0.478; P < 0.001]), whereas physicians were less likely to order a CXR (OR, 0.772 [0.667-0.894, P = 0.001]), bronchodilator (OR, 0.518 [0.449-0.596, P < 0.001]), or a corticosteroid (OR, 0.630 [0.531-0.749, P < 0.001]). CONCLUSIONS Nurse practitioners made fewer diagnostic and therapeutic orders. A clinical practice guideline on the diagnosis and management of children with bronchiolitis successfully decreased the use of nonrecommended tests and therapies among NP and physicians.
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Hartog K, Ardura-Garcia C, Hammer J, Kuehni CE, Barben J. Acute bronchiolitis in Switzerland - Current management and comparison over the last two decades. Pediatr Pulmonol 2022; 57:734-743. [PMID: 34889073 DOI: 10.1002/ppul.25786] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 11/02/2021] [Accepted: 12/07/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Although international guidelines and Cochrane reviews emphasize that therapies do not alter the natural course of acute viral bronchiolitis (AVB), they are still prescribed frequently. This survey evaluated self-reported management of AVB by Swiss pediatricians in 2019 and compared it with previous surveys. METHODS We performed a cross-sectional online survey of all board-certified pediatricians in Switzerland in November 2019 and compared the reported use of therapies with that reported in the 2001 and 2006 surveys. We used multivariable ordered logistic regression to assess factors associated with reported prescription of bronchodilators, corticosteroids, antibiotics, and physiotherapy. RESULTS Among 1618 contacted board-certified pediatricians, 884 returned the questionnaires (55% response rate). After exclusions were applied, 679 were included in the final analysis. Pediatricians working in primary care reported using therapeutics more frequently than those working in a hospital setting, either always or sometimes: bronchodilators 53% versus 38%, corticosteroids 37% versus 23%, and antibiotics 39% versus 22%. The opposite occurred with physiotherapy: 53% reported prescribing it in hospital and 44% in primary care. There was an overall decrease in the prescription of therapeutics and interventions for AVB from 2001 to 2019. The proportion who reported "always" prescribing corticosteroids decreased from 71% to 2% in primary care, and of those "always" prescribing bronchodilators from 55% to 1% in hospitals. CONCLUSION Although we observed a significant decrease since 2001, more effort is required to reduce the use of unnecessary therapies in children with AVB.
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Affiliation(s)
- Katharina Hartog
- Division of Pediatric Pulmonology, Children's Hospital of Eastern Switzerland, St Gallen, Switzerland
| | | | - Jürg Hammer
- Division of Respiratory and Critical Care, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Claudia E Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Division of Respiratory Medicine, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jürg Barben
- Division of Pediatric Pulmonology, Children's Hospital of Eastern Switzerland, St Gallen, Switzerland
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Hester G, Nickel AJ, Watson D, Bergmann KR. Factors Associated With Bronchiolitis Guideline Nonadherence at US Children's Hospitals. Hosp Pediatr 2021; 11:1102-1112. [PMID: 34493589 DOI: 10.1542/hpeds.2020-005785] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The objective with this study was to explore factors associated with nonadherence to national bronchiolitis guidelines at 52 children's hospitals. METHODS We included patients 1 month to 2 years old with emergency department (ED) or admission encounters between January 2016 and December 2018 and bronchiolitis diagnoses in the Pediatric Health Information System database. We excluded patients with any intensive care, stay >7 days, encounters in the preceding 30 days, chronic medical conditions, croup, pneumonia, or asthma. Guideline nonadherence was defined as receiving any of 5 tests or treatments: bronchodilators, chest radiographs, systemic steroids, antibiotics, and viral testing. Nonadherence outcomes were modeled by using mixed effects logistic regression with random effects for providers and hospitals. Adjusted odds ratio (aOR) >1 indicates greater likelihood of nonadherence. RESULTS A total of 198 028 encounters were included (141 442 ED and 56 586 admission), and nonadherence was 46.1% (ED: 40.2%, admissions: 61.0%). Nonadherence increased with patient age, with both ED and hospital providers being more likely to order tests and treatments for children 12 to 24 months compared with infants 1 ot 2 months (ED: aOR, 3.39; 95% confidence interval [CI], 3.20-3.60; admissions: aOR, 2.97; CI, 2.79-3.17]). Admitted non-Hispanic Black patients were more likely than non-Hispanic white patients to receive guideline nonadherent care (aOR, 1.16; CI, 1.10-1.23), a difference driven by higher use of steroids (aOR, 1.29; CI, 1.17-1.41) and bronchodilators (aOR, 1.39; CI, 1.31-1.48). Hospital effects were prominent for viral testing in ED and admission encounters (intraclass correlation coefficient of 0.35 and 0.32, respectively). CONCLUSIONS Multiple factors are associated with national bronchiolitis guideline nonadherence.
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Affiliation(s)
| | | | | | - Kelly R Bergmann
- Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota
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8
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Frazier SB, Walls C, Jain S, Plemmons G, Johnson DP. Reducing Chest Radiographs in Bronchiolitis Through High-Reliability Interventions. Pediatrics 2021; 148:peds.2020-014597. [PMID: 34344801 DOI: 10.1542/peds.2020-014597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Bronchiolitis is a leading cause of pediatric hospitalization in the United States, resulting in significant morbidity and health care resource use. Despite American Academy of Pediatrics recommendations against obtaining chest radiographs (CXRs) for bronchiolitis, variation in care continues. Historically, clinical practice guidelines and educational campaigns have had mixed success in reducing unnecessary CXR use. Our aim was to reduce CXR use for children <2 years with a primary diagnosis of bronchiolitis, regardless of emergency department (ED) disposition or preexisting conditions, from 42.1% to <15% of encounters by March 2020. METHODS A multidisciplinary team was created at our institution in 2012 to standardize bronchiolitis care. Given success with higher reliability interventions in asthma, similar interventions affecting workflow were subsequently pursued with bronchiolitis, starting in 2017, by using quality improvement science methods. The primary outcome was the percent of bronchiolitis encounters with a CXR. The balancing measure was return visits within 72 hours to the ED. Statistical process control charts were used to monitor and analyze data obtained from an internally created dashboard. RESULTS From 2012 to 2020, our hospital had 12 120 bronchiolitis encounters. Preimplementation baseline revealed a mean of 42.1% for CXR use. Low reliability interventions, like educational campaigns, resulted in unsustained effects on CXR use. Higher reliability interventions were associated with sustained reductions to 23.3% and 18.9% over the last 4 years. There was no change in ED return visits. CONCLUSIONS High-reliability workflow redesign was more effective in translating American Academy of Pediatrics recommendations into sustained practice than educational campaigns.
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Affiliation(s)
| | | | | | - Gregory Plemmons
- Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David P Johnson
- Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
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9
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Binnekamp M, van Stralen KJ, den Boer L, van Houten MA. Typical RSV cough: myth or reality? A diagnostic accuracy study. Eur J Pediatr 2021; 180:57-62. [PMID: 32533258 DOI: 10.1007/s00431-020-03709-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 05/19/2020] [Accepted: 05/28/2020] [Indexed: 11/25/2022]
Abstract
Respiratory syncytial virus (RSV) is well known for causing a potentially severe course of bronchiolitis in infants. Many paediatric healthcare workers claim to be able to diagnose RSV based on cough sound, which was evaluated in this study. Parents of children < 1 year old admitted to the paediatric ward because of airway complaints were asked to record cough sounds of their child. In all children, MLPA analysis-a variation of PCR analysis-on nasopharyngeal swab was performed (golden standard). Sixteen cough fragments representing 4 different viral pathogens were selected and presented to paediatric healthcare workers. Thirty-two paediatric nurses, 16 residents and 16 senior staff members were asked to classify the audio files and state whether the cough was due to RSV infection or not. Senior staff, nurses and residents correctly identified RSV with a sensitivity of 76.2%, 73.1% and 51.3% respectively. Correct exclusion of RSV cases was performed with a specificity of 60.8%, 60.2% and 65.3% respectively. Sensitivity ranged from 0 to 100% between colleagues; no one correctly identified all negatives. Residents had significantly lower rates of sensitivity than senior staff and nurses. This was strongly related to work experience, in which more than 3.5 years of work experience was related to the best result.Conclusion: Senior staff and nurses were better in making a cough-based diagnosis of RSV compared to residents. Both groups were able to detect the same proportion of true RSV patients based on cough sounds compared to bedside tests but could not validly distinguish RSV from other pathogens based on cough sounds. What is Known: • Many paediatric healthcare workers claim to be capable of diagnosing RSV in infants based on cough sound • Up to now, no studies investigating the recognisability of RSV based on cough sound are published What is New: • Senior staff and paediatric nurses performed better than various other bedside tests in diagnosing RSV but could not replace MLPA analysis • Residents need at least 3.5 years of work experience to be able to make a RSV diagnosis based on cough sound.
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Affiliation(s)
- Mirjam Binnekamp
- Department of Pediatrics, Spaarne Gasthuis, Boerhaavelaan 22, 2035 RC, Haarlem, The Netherlands
- Spaarne Gasthuis Academy, Spaarnepoort 1, 2134 TM, Hoofddorp, The Netherlands
| | | | - Larissa den Boer
- Spaarne Gasthuis Academy, Spaarnepoort 1, 2134 TM, Hoofddorp, The Netherlands
| | - Marlies A van Houten
- Department of Pediatrics, Spaarne Gasthuis, Boerhaavelaan 22, 2035 RC, Haarlem, The Netherlands.
- Spaarne Gasthuis Academy, Spaarnepoort 1, 2134 TM, Hoofddorp, The Netherlands.
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10
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Zipursky A, Kuppermann N, Finkelstein Y, Zemek R, Plint AC, Babl FE, Dalziel SR, Freedman SB, Steele DW, Fernandes RM, Florin TA, Stephens D, Kharbanda A, Roland D, Lyttle MD, Johnson DW, Schnadower D, Macias CG, Benito J, Schuh S. International Practice Patterns of Antibiotic Therapy and Laboratory Testing in Bronchiolitis. Pediatrics 2020; 146:peds.2019-3684. [PMID: 32661190 DOI: 10.1542/peds.2019-3684] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/06/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES International patterns of antibiotic use and laboratory testing in bronchiolitis in emergency departments are unknown. Our objective is to evaluate variation in the use of antibiotics and nonindicated tests in infants with bronchiolitis in 38 emergency departments in Pediatric Emergency Research Networks in Canada, the United States, Australia and New Zealand, the United Kingdom and Ireland, and Spain and Portugal. We hypothesized there would be significant variation, adjusted for patient characteristics. METHODS We analyzed a retrospective cohort study of previously healthy infants aged 2 to 12 months with bronchiolitis. Variables examined included network, poor feeding, dehydration, nasal flaring, chest retractions, apnea, saturation, respiratory rate, fever, and suspected bacterial infection. Outcomes included systemic antibiotic administration and urine, blood, or viral testing or chest radiography (CXR). RESULTS In total, 180 of 2359 (7.6%) infants received antibiotics, ranging from 3.5% in the United Kingdom and Ireland to 11.1% in the United States. CXR (adjusted odds ratio [aOR] 2.3; 95% confidence interval 1.6-3.2), apnea (aOR 2.2; 1.1-3.5), and fever (aOR 2.4; 1.7-3.4) were associated with antibiotic use, which did not vary across networks (P = .15). In total, 768 of 2359 infants (32.6%) had ≥1 nonindicated test, ranging from 12.7% in the United Kingdom and Ireland to 50% in Spain and Portugal. Compared to the United Kingdom and Ireland, the aOR (confidence interval) results for testing were Canada 5.75 (2.24-14.76), United States 4.14 (1.70-10.10), Australia and New Zealand 2.25 (0.86-5.74), and Spain and Portugal 3.96 (0.96-16.36). Testing varied across networks (P < .0001) and was associated with suspected bacterial infections (aOR 2.12; 1.30-2.39) and most respiratory distress parameters. Viral testing (591 of 768 [77%]) and CXR (507 of 768 [66%]) were obtained most frequently. CONCLUSIONS The rate of antibiotic use in bronchiolitis was low across networks and was associated with CXR, fever, and apnea. Nonindicated testing was common outside of the United Kingdom and Ireland and varied across networks irrespective of patient characteristics.
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Affiliation(s)
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, School of Medicine, University of California Davis and University of California Davis Health, Sacramento, California
| | - Yaron Finkelstein
- Division of Pediatric Emergency Medicine and.,Research Institute, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Roger Zemek
- Division of Pediatric Emergency Medicine, Faculty of Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Amy C Plint
- Division of Pediatric Emergency Medicine, Faculty of Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Franz E Babl
- Emergency Department, Murdoch Children's Research Institute, The Royal Children's Hospital and The University of Melbourne, Melbourne, Australia
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Hospital and the Departments of Surgery and Paediatrics: Child and Youth Health, School of Medicine, The University of Auckland, Auckland, New Zealand
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital and
| | - Dale W Steele
- Department of Pediatric Emergency Medicine, Hasbro Children's Hospital and Departments of Emergency Medicine and Pediatrics, Warren Alpert Medical School and Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Ricardo M Fernandes
- Department of Pediatrics, Hospital de Santa Maria and Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
| | - Todd A Florin
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University and Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Derek Stephens
- Research Institute, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Anupam Kharbanda
- Department of Pediatric Emergency Medicine, Children's Hospital of Minnesota, Minneapolis, Minnesota
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic Group, Children's Emergency Department, Leicester Royal Infirmary, Leicester, United Kingdom.,Social Science Applied to Healthcare Improvement Research Group, Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Mark D Lyttle
- Paediatric Emergency Department, Bristol Royal Hospital for Children, Bristol, United Kingdom.,Faculty of Health and Applied Life Sciences, University of the West of England, Bristol, United Kingdom
| | - David W Johnson
- Departments of Pediatrics, Emergency Medicine, and Physiology and Pharmacology, Alberta Children's Hospital Research Institute, Cumming School of Medicine, Calgary, Alberta, Canada
| | - David Schnadower
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Charles G Macias
- Division of Pediatric Emergency Medicine, University Hospitals Rainbow Babies and Children's Hospital and Case Western Reserve University, Cleveland, Ohio; and
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Bizkaia, Spain
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine and .,Research Institute, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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