Variations in Treating Acute Bronchiolitis in the ED
Variations in Treating Acute Bronchiolitis in the ED
To our knowledge, this is the first study to explore, through a nationwide dataset, the practice variations between EPs and pediatricians in the management of acute bronchiolitis in ED. Acute bronchiolitis is a self-limiting viral respiratory tract infection in infancy, and supportive care is the mainstay treatment. Many studies have demonstrated variation in diagnostic testing, treatment, hospital admission rates, and length of stay for bronchiolitis before the release of the 2006 AAP bronchiolitis recommendations; however, use of non–evidence-based testing and therapies remains common. The discrepancy between guideline and real-life clinical practice deserves further studies to verify.
The findings of this study demonstrated both EPs (3.7%–63.7%) and pediatricians (1.8%–46%) had high rates of ordering diagnostic testing for their patients. In addition, EPs tended to order diagnostic tests for the evaluation of acute bronchiolitis more frequently than did pediatricians. Use of diagnostic testing is one of the competencies during emergency medicine residency training; therefore, EPs tend to require diagnostic testing to rule out other severe conditions as a result of their training. However, diagnostic testing, such as laboratory tests, plays a limited role in acute bronchiolitis management and may prolong patient's length of stay, leading to ED overcrowding. Overuse of ineffective diagnostic testing may reflect uncertainty regarding the presenting diagnosis, and a trend in "defensive medicine" (i.e., to avoid misdiagnosis), which is common in ED. In the current study, about 20%–30% of patients underwent laboratory testing in the ED, which is quite different, for example, from the 0%–25.7% rate found in Spanish EDs. Although CBCs and blood cultures are frequently used to detect bacterial infection, they do not seem to be necessary in acute bronchiolitis.
Johnson et al. reported a marked decrease in the use of chest x-ray from 65.3% to 48.6% after the release of the 2006 AAP recommendations for the management of acute bronchiolitis. In addition, only 14.9% of patients with acute bronchiolitis underwent chest x-ray study in Spain. In Taiwan, the current results demonstrate that 63.7% and 46% patients underwent chest x-ray study when managed by EPs and pediatricians, respectively. The high reliance on chest x-ray study in both EP and pediatrician groups suggested that they had less confidence or experience in their clinical diagnostic skills. Chest x-ray study is a common diagnostic test for evaluating children presenting with dyspnea and wheeze in the ED. The list of differential diagnoses of wheeze is broad, and EPs tend to order diagnostic testing to rule out alternative diagnoses. When is the appropriate time to order a chest x-ray study for a patient presenting with acute bronchiolitis? Carsin et al. suggested that chest x-ray study was useful when the hospitalized child did not improve at the expected rate or if the condition is severe.
In the current studies, medications, such as bronchodilators and corticosteroids, were used widely for the management of acute bronchiolitis. However, systematic reviews have suggested that these medications are not effective in improving the clinical course of the illness. On the other hand, a recent study showed that a combination of nebulized epinephrine and oral dexamethasone could decrease the risk of hospital admission compared with placebo. Johnson et al. reported that there was no difference in the use of bronchodilators (53.6% vs. 54.2%; p = 0.91) and corticosteroids (21.9% vs. 17.8%; p = 0.31) in ED after the introduction of the 2006 AAP bronchiolitis recommendations. In our study, only 2.4% of patients received corticosteroids, and 26.9% received bronchodilators. Bronchodilators remained the first choice of medication for the treatment of the patients with dyspnea and wheezing. Actually, the 2006 AAP guideline stated that bronchodilators might be continued if the patients showed clinical response.
Evidence-based guidelines can contribute to improve care only if they change actual practice of the physicians, however, the implication of guidelines into to physician's daily practice remain unsatisfactory. EPs and pediatricians receive significantly different training, which likely affects their practice patterns in managing pediatric patients in the ED. In addition, EPs are likely unaware of the various specialty clinical practice guidelines. Benchmarking has been attributed to a significant decline in the use of ineffective interventions, such as bronchodilators, in bronchiolitis and may be a method for improving the practice patterns.
One of the strengths of this cross-sectional study was the use of the LHID2010 nationwide database. In Taiwan, since 1995, most health care services have been provided by National Health Insurance. The National Health Insurance system covers nearly 98% of the Taiwanese population; therefore, the data represent the true clinical pattern of physician practice in Taiwan.
This study has some limitations. The major limitation was lack of clinical data for individual cases and no Disease Severity Index information in the nationwide database. Clinical data, including body temperature, respiratory rate, respiratory effort, and oxygen saturation were important clinical parameters for the physicians to do decision making. Accordingly, we did not know the severity of acute bronchiolitis patients in each group. To overcome this limitation, we used ICD-9-CM code of clinical symptoms including fever, vomiting, dehydration, and respiratory distress for adjustment. Although supportive care is the mainstay treatment of acute bronchiolitis, the Respiratory Distress Assessment Instrument can guide management and disposition. It is reasonable that patients with higher illness severity should receive more diagnostic and therapeutic interventions. In this study, 20.8% of patients in EP group needed intravenous hydration and 36% of patient needed admission, implying that EPs were caring for patients with more severe condition. Second, there were no outcomes to compare. The quality of care for pediatric emergency patients, including mortality, 72-h revisit rate, and length of ED stay, could not be assessed. A previous study showed that, although EPs used more medical resources to treat pediatric patients, the management of critically ill patients was similar to that of pediatricians. Third, nearly 60% patients were treated at community EDs. In Taiwan, patients can seek medical care in academic medical center EDs or community EDs without limitation or restriction or transfer system. However, the medical resources, for example, medical and paramedical staff, high-technology diagnostic imaging, and pediatric subspecialists were limited in community EDs and may not be enough, even in the medical center in Taiwan. Different practice environments can affect physician's decision making, which could not be evaluated in this study. Fourth, the number of pediatric emergency medicine specialists is limited in Taiwan and they were excluded from our study. Therefore, the results should be read with caution and used for generalizability with other countries.
Discussion
To our knowledge, this is the first study to explore, through a nationwide dataset, the practice variations between EPs and pediatricians in the management of acute bronchiolitis in ED. Acute bronchiolitis is a self-limiting viral respiratory tract infection in infancy, and supportive care is the mainstay treatment. Many studies have demonstrated variation in diagnostic testing, treatment, hospital admission rates, and length of stay for bronchiolitis before the release of the 2006 AAP bronchiolitis recommendations; however, use of non–evidence-based testing and therapies remains common. The discrepancy between guideline and real-life clinical practice deserves further studies to verify.
The findings of this study demonstrated both EPs (3.7%–63.7%) and pediatricians (1.8%–46%) had high rates of ordering diagnostic testing for their patients. In addition, EPs tended to order diagnostic tests for the evaluation of acute bronchiolitis more frequently than did pediatricians. Use of diagnostic testing is one of the competencies during emergency medicine residency training; therefore, EPs tend to require diagnostic testing to rule out other severe conditions as a result of their training. However, diagnostic testing, such as laboratory tests, plays a limited role in acute bronchiolitis management and may prolong patient's length of stay, leading to ED overcrowding. Overuse of ineffective diagnostic testing may reflect uncertainty regarding the presenting diagnosis, and a trend in "defensive medicine" (i.e., to avoid misdiagnosis), which is common in ED. In the current study, about 20%–30% of patients underwent laboratory testing in the ED, which is quite different, for example, from the 0%–25.7% rate found in Spanish EDs. Although CBCs and blood cultures are frequently used to detect bacterial infection, they do not seem to be necessary in acute bronchiolitis.
Johnson et al. reported a marked decrease in the use of chest x-ray from 65.3% to 48.6% after the release of the 2006 AAP recommendations for the management of acute bronchiolitis. In addition, only 14.9% of patients with acute bronchiolitis underwent chest x-ray study in Spain. In Taiwan, the current results demonstrate that 63.7% and 46% patients underwent chest x-ray study when managed by EPs and pediatricians, respectively. The high reliance on chest x-ray study in both EP and pediatrician groups suggested that they had less confidence or experience in their clinical diagnostic skills. Chest x-ray study is a common diagnostic test for evaluating children presenting with dyspnea and wheeze in the ED. The list of differential diagnoses of wheeze is broad, and EPs tend to order diagnostic testing to rule out alternative diagnoses. When is the appropriate time to order a chest x-ray study for a patient presenting with acute bronchiolitis? Carsin et al. suggested that chest x-ray study was useful when the hospitalized child did not improve at the expected rate or if the condition is severe.
In the current studies, medications, such as bronchodilators and corticosteroids, were used widely for the management of acute bronchiolitis. However, systematic reviews have suggested that these medications are not effective in improving the clinical course of the illness. On the other hand, a recent study showed that a combination of nebulized epinephrine and oral dexamethasone could decrease the risk of hospital admission compared with placebo. Johnson et al. reported that there was no difference in the use of bronchodilators (53.6% vs. 54.2%; p = 0.91) and corticosteroids (21.9% vs. 17.8%; p = 0.31) in ED after the introduction of the 2006 AAP bronchiolitis recommendations. In our study, only 2.4% of patients received corticosteroids, and 26.9% received bronchodilators. Bronchodilators remained the first choice of medication for the treatment of the patients with dyspnea and wheezing. Actually, the 2006 AAP guideline stated that bronchodilators might be continued if the patients showed clinical response.
Evidence-based guidelines can contribute to improve care only if they change actual practice of the physicians, however, the implication of guidelines into to physician's daily practice remain unsatisfactory. EPs and pediatricians receive significantly different training, which likely affects their practice patterns in managing pediatric patients in the ED. In addition, EPs are likely unaware of the various specialty clinical practice guidelines. Benchmarking has been attributed to a significant decline in the use of ineffective interventions, such as bronchodilators, in bronchiolitis and may be a method for improving the practice patterns.
One of the strengths of this cross-sectional study was the use of the LHID2010 nationwide database. In Taiwan, since 1995, most health care services have been provided by National Health Insurance. The National Health Insurance system covers nearly 98% of the Taiwanese population; therefore, the data represent the true clinical pattern of physician practice in Taiwan.
Limitations
This study has some limitations. The major limitation was lack of clinical data for individual cases and no Disease Severity Index information in the nationwide database. Clinical data, including body temperature, respiratory rate, respiratory effort, and oxygen saturation were important clinical parameters for the physicians to do decision making. Accordingly, we did not know the severity of acute bronchiolitis patients in each group. To overcome this limitation, we used ICD-9-CM code of clinical symptoms including fever, vomiting, dehydration, and respiratory distress for adjustment. Although supportive care is the mainstay treatment of acute bronchiolitis, the Respiratory Distress Assessment Instrument can guide management and disposition. It is reasonable that patients with higher illness severity should receive more diagnostic and therapeutic interventions. In this study, 20.8% of patients in EP group needed intravenous hydration and 36% of patient needed admission, implying that EPs were caring for patients with more severe condition. Second, there were no outcomes to compare. The quality of care for pediatric emergency patients, including mortality, 72-h revisit rate, and length of ED stay, could not be assessed. A previous study showed that, although EPs used more medical resources to treat pediatric patients, the management of critically ill patients was similar to that of pediatricians. Third, nearly 60% patients were treated at community EDs. In Taiwan, patients can seek medical care in academic medical center EDs or community EDs without limitation or restriction or transfer system. However, the medical resources, for example, medical and paramedical staff, high-technology diagnostic imaging, and pediatric subspecialists were limited in community EDs and may not be enough, even in the medical center in Taiwan. Different practice environments can affect physician's decision making, which could not be evaluated in this study. Fourth, the number of pediatric emergency medicine specialists is limited in Taiwan and they were excluded from our study. Therefore, the results should be read with caution and used for generalizability with other countries.
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