Practice Variations between Emergency Physicians and Pediatricians in Treating Acute Bronchiolitis in the Emergency Department: A Nationwide Study

Ho, Sai‐Wai; Huang, Ka-Yi; Teng, Ying‐Hock; Ku, Min‐Sho; Chiou, Jeng‐Yuan

doi:10.1016/j.jemermed.2014.12.032

Cited by 10 publications

(7 citation statements)

References 37 publications

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“…In contrast, MEDIC baseline performance across the other 3 quality initiatives was similar to findings from previous investigations showing wide variation in practice and the opportunity for quality improvement, including use of the PECARN CT rule for pediatric minor head injury, 36,42 use of chest radiographs for pediatric respiratory conditions, [43][44][45] and diagnostic yield of CTs for suspected pulmonary embolism. [46][47][48][49][50] However, many of these previous studies were limited to assessments of single centers and referral or pediatric specialty hospitals.…”

Section: Discussionsupporting

confidence: 73%

Baseline Performance of Real-World Clinical Practice Within a Statewide Emergency Medicine Quality Network: The Michigan Emergency Department Improvement Collaborative (MEDIC)

Kocher

Arora

Bassin

et al. 2020

Annals of Emergency Medicine

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Study objective: Large-scale quality and performance measurement across unaffiliated hospitals is an important strategy to drive practice change. The Michigan Emergency Department Improvement Collaborative (MEDIC), established in 2015, has baseline performance data to identify practice variation across 15 diverse emergency departments (EDs) on key emergency care quality indicators.Methods: MEDIC is a unique physician-led partnership supported by a major third-party payer. Member sites contribute electronic health record data and trained abstractors add supplementary data for eligible cases. Quality measures include computed tomography (CT) appropriateness for minor head injury, using the Canadian CT Head Rule for adults and Pediatric Emergency Care Applied Network rules for children; chest radiograph use for children with asthma, bronchiolitis, and croup; and diagnostic yield of CTs for suspected pulmonary embolism. Baseline performance was established with statistical process control charts.

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Section: Discussionsupporting

confidence: 73%

Baseline Performance of Real-World Clinical Practice Within a Statewide Emergency Medicine Quality Network: The Michigan Emergency Department Improvement Collaborative (MEDIC)

Kocher

Arora

Bassin

et al. 2020

Annals of Emergency Medicine

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“…Furthermore, the use of these varies considerably among countries and institutions. [15][16][17][18] Infants with bronchiolitis are at low risk of serious bacterial infections, [19][20][21] and experts discourage routine laboratory testing and antibiotic use unless bacterial infections are suspected. 1,[6][7][8][9][10][11][12][13][14] Although the use of these interventions remains common, 22,23 our knowledge about their use has been derived primarily from studies of hospitalized patients.…”

mentioning

confidence: 99%

International Practice Patterns of Antibiotic Therapy and Laboratory Testing in Bronchiolitis

Zipursky¹,

Kuppermann

Finkelstein

et al. 2020

Pediatrics

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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.

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“…27-29 General emergency physicians may not be aware of pediatric specific guidelines or guidelines published in pediatric journals. 16 In addition, guidelines are often more readily available and disseminated in an academic setting. 28 Although more PEDs were academic (41.9%) compared with GEDs (21.1%) in our study, differences between PEDs and GEDs persisted after adjustment for hospital academic status.…”

Section: Discussionmentioning

confidence: 99%

“…15 A study from Taiwan suggested that compared to pediatricians, emergency medicine physicians are more likely to obtain diagnostic testing in children with bronchiolitis, with a discrepancy between what occurs in clinical care and local guideline recommendations. 16 In the NHAMCS study cited above, while there was no change in non-recommended therapies after guideline publication, PEDs were less likely to use radiographs, steroids and antibiotics and more likely to use bronchodilators during the overall 9-year study period. 3 Differences in care in PEDs and GEDs were not examined in detail, however, before and after guideline publication as a possible explanation for the study's overall findings.…”

Section: Introductionmentioning

confidence: 97%

Emergency Department Management of Bronchiolitis in the United States

et al. 2019

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Objective To examine differences between general and pediatric emergency departments in adherence to AAP bronchiolitis management guidelines. Methods We conducted a nationally representative study of ED visits by infants <24 months of age with bronchiolitis from 2002-2011 using the National Hospital Ambulatory Medical Care Survey. Diagnostic testing (complete blood counts, radiographs) and medication use (albuterol, corticosteroids, antibiotics and intravenous fluids) in GEDs were compared with PEDs before and after 2006 AAP guideline publication. Weighted percentages were compared and logistic regression evaluated the association between ED type and resource use. Results Of over 2.5 million ED visits for bronchiolitis from 2002-2011, 77.3% occurred in GEDs. GEDs were more likely to use radiography (62.7% vs. 42.1%, aOR 2.4 [95%CI 1.4,4.1]), antibiotics (41.3% vs. 18.8%, aOR 2.8 [1.5,5.2]), and corticosteroids (24.3% vs. 12.5%, aOR 2.1 [1.0,4.5]) compared to PEDs. Compared to pre-guideline, after guideline publication PEDs had a greater decrease in radiography use (-19.7%, 95%CI -39.3,-0.03) compared with GEDs (-12.2%, 95%CI -22.3,-2.1) and PEDs showed a significant decline in corticosteroid use (-12.4%, 95%CI -22.1,-2.8%) whereas GEDs showed no significant decline (-4.6%, 95%CI -13.5, 4.3). Conclusions The majority of ED visits for bronchiolitis in the US occurred in GEDs, yet GEDs had increased use of radiography, corticosteroid, and antibiotics and did not show substantial declines with national guideline publication. Given that national guidelines discourage the use of such tests and treatments in the management of bronchiolitis, efforts are required to decrease ED use of these resources in infants with bronchiolitis, particularly in GEDs.

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Practice Variations between Emergency Physicians and Pediatricians in Treating Acute Bronchiolitis in the Emergency Department: A Nationwide Study

Cited by 10 publications

References 37 publications

Baseline Performance of Real-World Clinical Practice Within a Statewide Emergency Medicine Quality Network: The Michigan Emergency Department Improvement Collaborative (MEDIC)

Baseline Performance of Real-World Clinical Practice Within a Statewide Emergency Medicine Quality Network: The Michigan Emergency Department Improvement Collaborative (MEDIC)

International Practice Patterns of Antibiotic Therapy and Laboratory Testing in Bronchiolitis

Emergency Department Management of Bronchiolitis in the United States

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