Gastroenteritis Care in the US and Canada: Can Comparative Analysis Improve Resource Use?

Acute gastroenteritis (AGE), the most common cause of dehydration in infants and children, accounts for 1.5 million annual outpatient visits and 10% of all pediatric hospital admissions.^1–3  Although severely ill children may require intravenous (IV) rehydration, the Centers for Disease Control and Prevention and the American Academy of Pediatrics recommendation for children with mild to moderate dehydration is to use oral rehydration therapy (ORT).^1,3  ORT has many benefits when compared with IV rehydration: lower cost, eliminated need for an IV catheter to be placed, shortened emergency department (ED) and hospital stays, improved parental satisfaction, and empowered parents to continue therapy at home.^1,3,4  Additionally, a meta-analysis comparing ORT with IV rehydration revealed low risk of treatment failure for ORT (<5%).⁴  Despite these advantages, IV rehydration is still commonly used for mild to moderate dehydration in AGE, with wide interinstitutional and interprovider practice variation.^5,6 

In this issue of Pediatrics, Freedman et al compare resource use and outcomes among children with AGE enrolled in 1 of 2 ED-based randomized controlled trials of probiotics conducted by the Pediatric Emergency Care Applied Research Network in the United States and the Pediatric Emergency Research Care network in Canada.^7–9  Although they are separate trials, the similarity of enrollment criteria allowed these data to be combined to compare children with AGE in 10 US EDs to 6 Canadian EDs. The authors found no difference in subsequent unplanned health care visits, defined as an ED or primary care physician (PCP) visit for AGE within 7 days of the index visit, despite more frequent use of IV rehydration in US EDs (adjusted odds ratio [aOR]: 4.6; 95% confidence interval [CI]: 2.9–7.1). The study researchers conclude that more frequent use of IV rehydration in the United States did not result in improved outcomes with respect to repeat visits and that the US EDs and providers could further limit use of IV rehydration without increasing adverse outcomes.

This study was methodologically rigorous and had several notable strengths. Because the 2 large data sets had similar inclusion criteria and standardized follow-up, the authors were able to control for patient-level characteristics, such as severity of illness, which is unique for cross-country comparisons. However, although the article’s conclusion that use of IV rehydration does not prevent revisits is consistent with previous reports in the medical literature,^4,10,11  the study’s stratified analysis leads to further questions. Notably, although overall revisits were the same for patients in both countries, ED revisit rate was lower in the United States (aOR: 0.61; 95% CI: 0.39–0.95) whereas primary care revisits were not different between the populations (aOR: 0.76 for United States versus Canada; 95% CI: 0.45–1.28). The reason why US patients were less likely than Canadian patients to return to the ED, but not to their PCP, cannot be discerned from the current study.

Drivers behind a parent’s decision to follow-up after an ED visit with their pediatrician versus return to the ED likely differ. In previous studies of children with AGE in US EDs, three-quarters of providers recommended short-term PCP follow-up for children with gastroenteritis after discharge,¹²  and 45% of caregivers followed this recommendation.¹³  This implies that a substantial proportion of “unscheduled” visits to PCPs made after ED discharge may in fact be planned follow-up visits and not reflective of treatment failure. In contrast, an ED return visit is more likely to reflect symptom progression or treatment failure.

The data in this study are consistent with previous literature revealing vastly different ED return visit rates for children with AGE in the 2 countries: 16% in Canada¹⁴  versus 2.2% in the United States.¹⁵  It is not clear why US children return to the ED less frequently with AGE symptoms than Canadian children. One possible explanation is more frequent ED administration and prescription of ondansetron. The authors found more frequent use of ondansetron in the United States in this study,⁷  and previous studies of pediatric AGE have observed an association between ondansetron use and decreased ED revisits and improved clinical outcomes.¹⁶  Of course, more US children received IV fluids, and although this did not change overall rates of revisit, it may have influenced likelihood of returning to the ED. Finally, factors intrinsic to the health care system itself, such as high out-of-pocket medical expenses in the United States, may have dissuaded patients and families from returning to the ED, even if symptoms had not improved.¹⁷ 

Although it is not clear which component of ED or follow-up care in the United States resulted in decreased ED return visits relative to those in Canada, the difference in resource use between Canadian and US EDs across a host of conditions remains striking.^18–20  For many of these conditions, increasing resource use in the US has not resulted in improved outcomes.^18,21,22  This is among the reasons that the US health care system is the most expensive in the world but has only mediocre health-related outcomes compared with other nations.^23,24  With variation in care comes the opportunity to reflect on why practice patterns differ so dramatically and ultimately drive improvement in care. Freedman et al have laid the groundwork for such improvement for children with AGE.

 
• AGE

  acute gastroenteritis

 
• aOR

  adjusted odds ratio

 
• CI

  confidence interval

 
• ED

  emergency department

 
• IV

  intravenous

 
• ORT

  oral rehydration therapy

 
• PCP

  primary care physician