Video Abstract
Between-country variation in health care resource use and its impact on outcomes in acute care settings have been challenging to disentangle from illness severity by using administrative data.
We conducted a preplanned analysis employing patient-level emergency department (ED) data from children enrolled in 2 previously conducted clinical trials. Participants aged 3 to <48 months with <72 hours of gastroenteritis were recruited in pediatric EDs in the United States (N = 10 sites; 588 participants) and Canada (N = 6 sites; 827 participants). The primary outcome was an unscheduled health care provider visit within 7 days; the secondary outcomes were intravenous fluid administration and hospitalization at or within 7 days of the index visit.
In adjusted analysis, unscheduled revisits within 7 days did not differ (adjusted odds ratio [aOR]: 0.72; 95% confidence interval (CI): 0.50 to 1.02). At the index ED visit, although participants in Canada were assessed as being more dehydrated, intravenous fluids were administered more frequently in the United States (aOR: 4.6; 95% CI: 2.9 to 7.1). Intravenous fluid administration rates did not differ after enrollment (aOR: 1.4; 95% CI: 0.7 to 2.8; US cohort with Canadian as referent). Overall, intravenous rehydration was higher in the United States (aOR: 3.8; 95% CI: 2.5 to 5.7). Although hospitalization rates during the 7 days after enrollment (aOR: 1.1; 95% CI: 0.4 to 2.6) did not differ, hospitalization at the index visit was more common in the United States (3.9% vs 2.3%; aOR: 3.2; 95% CI: 1.6 to 6.8).
Among children with gastroenteritis and similar disease severity, revisit rates were similar in our 2 study cohorts, despite lower rates of intravenous rehydration and hospitalization in Canadian-based EDs.
A 2019 national survey reported differences in treatment methods between general pediatricians (GPs) and pediatric gastroenterologists (PGs) in South Korea.[2] While both groups managed dehydration with IV nous fluid infusions and showed similar hospitalization rates, GPs more commonly prescribed anti-emetics and probiotics and educated the patients on meal adjustments than did PGs. Despite AGE being one of the most common pediatric diseases, treatment prescriptions slightly differ between GPs and PGs in South Korea.
The above mentioned studies showed unexpectedly high IV fluid administration and hospitalization rates. A multicenter study from 31 hospitals evaluating the indications for hospitalization in pediatric AGE reported that 57.5% of hospitalized patients did not require hospitalization.[3] Oral rehydration solution (ORS) therapy failure is an important indication for hospitalization in pediatric AGE, as described in the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) management guidelines.[4] ORS therapy is more effective and less invasive than IV rehydration for mild to moderate dehydration. Practical emergency use of clinical decision support systems, such as a clinical dehydration scale, increased compliance as well as ORS therapy success rates from 52% to 65% in a randomized controlled trial.[5]
Most children dislike ORS because of its bad taste. However, the above ESPGHAN guidelines strongly recommended administration of low-osmolarity ORS as first-line therapy for AGE but only weakly recommended fruit-flavored ORS.
A high hospitalization rate for pediatric AGE may not be confined to these countries. Easy accessibility to the healthcare system and reduced procedural complications could increase IV hydration and hospitalization rates. Therefore, all pediatricians need to carefully assess the degree of dehydration and indications for hospitalization in pediatric AGE patients.
References
1. Freedman SB, Roskind CG, Schuh S, VanBuren JM, Norris JG, Tarr PI, et al.; Pediatric Emergency Research Canada; Pediatric Emergency Care Applied Research Networks. Comparing pediatric gastroenteritis emergency department care in Canada and the United States. Pediatrics. 2021;147:e2020030890.
2. Seo JH, Shim JO, Choe BH, Moon JS, Kang KS, Chung JY. Management of acute gastroenteritis in children: a survey among members of the Korean Society of Pediatric Gastroenterology, Hepatology, and Nutrition. Pediatr Gastroenterol Hepatol Nutr. 2019;22:431-440.
3. King CK, Glass R, Bresee JS, Duggan C. Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003;52:1-16.
4. Guarino A, Ashkenazi S, Gendrel D, Lo Vecchio A, Shamir R, Szajewska H; European Society for Pediatric Gastroenterology, Hepatology, and Nutrition; European Society for Pediatric Infectious Diseases. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition/European Society for Pediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe: update 2014. J Pediatr Gastroenterol Nutr. 2014;59:132-152.
5. Geurts D, de Vos-Kerkhof E, Polinder S, Steyerberg E, van der Lei J, Moll H, et al. Implementation of clinical decision support in young children with acute gastroenteritis: a randomized controlled trial at the emergency department. Eur J Pediatr. 2017;176:173-181.