急性细支气管炎的实践差异：一项儿科急诊研究网络的研究

Practice Variation in Acute Bronchiolitis: A Pediatric Emergency Research Networks Study.

作者信息

Schuh Suzanne, Babl Franz E, Dalziel Stuart R, Freedman Stephen B, Macias Charles G, Stephens Derek, Steele Dale W, Fernandes Ricardo M, Zemek Roger, Plint Amy C, Florin Todd A, Lyttle Mark D, Johnson David W, Gouin Serge, Schnadower David, Klassen Terry P, Bajaj Lalit, Benito Javier, Kharbanda Anupam, Kuppermann Nathan

机构信息

Division of Paediatric Emergency Medicine and.

The Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada.

出版信息

Pediatrics. 2017 Dec;140(6). doi: 10.1542/peds.2017-0842.

DOI:10.1542/peds.2017-0842

PMID:29184035

Abstract

BACKGROUND AND OBJECTIVES

Studies characterizing hospitalizations in bronchiolitis did not identify patients receiving evidence-based supportive therapies (EBSTs). We aimed to evaluate intersite and internetwork variation in receipt of ≥1 EBSTs during the hospital management of infants diagnosed with bronchiolitis in 38 emergency departments of pediatric emergency research networks in Canada, the United States, Australia, New Zealand, the United Kingdom, Ireland, Spain, and Portugal. We hypothesized that there would be significant variation, adjusted for patient characteristics.

METHODS

Retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was that hospitalization occurred with EBST (ie, parenteral fluids, oxygen, or airway support).

RESULTS

Out of 3725 participants, 1466 (39%) were hospitalized, and 1023 out of 1466 participants (69.8%) received EBST. The use of EBST varied by site ( < .001; range 6%-99%, median 23%), but not by network ( = .2). Significant multivariable predictors and their odds ratios (ORs) were as follows: age (0.9), oxygen saturation (1.3), apnea (3.4), dehydration (3.2), nasal flaring and/or grunting (2.4), poor feeding (2.1), chest retractions (1.9), and respiratory rate (1.2). The use of pharmacotherapy and radiography varied by network and site ( < .001), with respective intersite ranges 2% to 79% and 1.6% to 81%. Compared with Australia and New Zealand, the multivariable OR for the use of pharmacotherapy in Spain and Portugal was 22.7 (95% confidence interval [CI]: 4.5-111), use in Canada was 11.5 (95% CI: 3.7-36), use in the United States was 6.8 (95% CI: 2.3-19.8), and use in the United Kingdom was 1.4 (95% CI: 0.4-4.2). Compared with United Kingdom, OR for radiography use in the United States was 4.9 (95% CI 2.0-12.2), use in Canada was 4.9 (95% CI 1.9-12.6), use in Spain and Portugal was 2.4 (95% CI 0.6-9.8), and use in Australia and New Zealand was 1.8 (95% CI 0.7-4.7).

CONCLUSIONS

More than 30% of infants hospitalized with bronchiolitis received no EBST. The hospital site was a source of variation in all study outcomes, and the network also predicted the use of pharmacotherapy and radiography.

摘要

背景与目的

关于细支气管炎住院治疗特征的研究未明确接受循证支持性治疗（EBST）的患者。我们旨在评估加拿大、美国、澳大利亚、新西兰、英国、爱尔兰、西班牙和葡萄牙等国儿科急诊研究网络的38个急诊科中，诊断为细支气管炎的婴儿在住院治疗期间接受≥1种EBST的机构间及网络间差异。我们假设，在对患者特征进行调整后会存在显著差异。

方法

对年龄<12个月、既往健康的细支气管炎婴儿进行回顾性队列研究。我们的主要结局是住院期间接受了EBST（即肠外补液、吸氧或气道支持）。

结果

在3725名参与者中，1466名（39%）住院治疗，其中1466名参与者中的1023名（69.8%）接受了EBST。EBST的使用情况因机构而异（P<0.001；范围为6% - 99%，中位数为23%），但在网络间无差异（P = 0.2）。显著的多变量预测因素及其比值比（OR）如下：年龄（0.9）、血氧饱和度（1.3）、呼吸暂停（3.4）、脱水（3.2）、鼻扇动和/或呻吟（2.4）、喂养困难（2.1）、胸壁凹陷（1.9）和呼吸频率（1.2）。药物治疗和影像学检查的使用情况在网络和机构间存在差异（P<0.001），机构间各自的范围分别为2%至79%和1.6%至81%。与澳大利亚和新西兰相比，西班牙和葡萄牙使用药物治疗的多变量OR为22.7（95%置信区间[CI]：4.5 - 111），加拿大为11.5（95% CI：3.7 - 36），美国为6.8（95% CI：2.3 - 19.8），英国为1.4（95% CI：0.4 - 4.2）。与英国相比，美国影像学检查使用的OR为4.9（95% CI 2.0 - 12.2），加拿大为4.9（95% CI 1.9 - 12.6），西班牙和葡萄牙为2.4（95% CI 0.6 - 9.8），澳大利亚和新西兰为1.8（95% CI 0.7 - 4.7）。