Stephen B Freedman1, Matt Hall2, Samir S Shah3, Anupam B Kharbanda4, Paul L Aronson5, Todd A Florin6, Rakesh D Mistry7, Charles G Macias8, Mark I Neuman9. 1. Sections of Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital and Research Institute, University of Calgary, Calgary, Alberta. 2. Children's Hospital Association, Overland Park, Kansas. 3. Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio. 4. Division of Pediatric Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis. 5. Section of Emergency Medicine, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut. 6. Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio. 7. Division of Emergency Medicine, Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia. 8. Section of Emergency Medicine, Department of Pediatrics, Center for Clinical Effectiveness, Baylor College of Medicine/Texas Children's Hospital, Houston. 9. Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.
Abstract
IMPORTANCE: Ondansetron hydrochloride use in children with gastroenteritis is increasing rapidly; however, little is known about its impact on outcomes. OBJECTIVE: To determine whether increasing emergency department ondansetron use has resulted in a reduction in intravenous rehydration rates. DESIGN, SETTING, AND PARTICIPANTS: Retrospective observational analysis of eligible visits included in the Pediatric Health Information System administrative database. Eligible institutions included 18 emergency departments geographically distributed across the United States, and participants included 804,000 patients aged 0 to 18 years who were diagnosed as having gastroenteritis in an emergency department at an eligible participating institution between January 1, 2002, and December 31, 2011. INTERVENTIONS: The presence or absence of oral ondansetron administration was identified for each patient through database review. Visits were categorized based on institutional ondansetron use: low (<5% administered ondansetron), medium (5%-25%), or high (>25%). MAIN OUTCOMES AND MEASURES: We conducted hospital-level analyses of the associations between ondansetron use and 3 outcomes: intravenous rehydration (primary), hospitalization, and emergency department revisits within 3 days. Time-series regression models were used, adjusting for demographic characteristics, laboratory testing, diagnostic imaging, and rotavirus infection. RESULTS: A total of 804,000 eligible patient visits were identified. Oral ondansetron use increased from a median institutional rate of 0.11% (interquartile range, 0.04%-0.44%) of patient visits in 2002 to 42.2% (interquartile range, 37.5%-49.1%) in 2011 (P < .001). Intravenous rehydration was administered to 43,413 of 232,706 children (18.7%) during the low ondansetron period compared with 59,450 of 334,264 (17.8%) during the high ondansetron period (adjusted percentage change = -0.33%; 95% CI, -1.86% to 1.20%). During the transition from low to high ondansetron use, we observed no change in the hospitalization rate (adjusted percentage change = -0.33%; 95% CI, -0.95% to 0.29%), but emergency department revisits decreased (adjusted percentage change = -0.31%; 95% CI, -0.49% to -0.13%). The change in all 3 outcomes varied widely between low and high ondansetron use categories at an institutional level. Oral ondansetron was provided to 13.5% (95% CI, 13.3% to 13.7%) of children administered intravenous rehydration. CONCLUSIONS AND RELEVANCE: Although ondansetron use increased during the study period, intravenous rehydration rates were unchanged. Most children administered intravenous fluids did not receive oral ondansetron. Our findings highlight the need to focus efforts to administer ondansetron to children at greatest risk for oral rehydration failure.
IMPORTANCE: Ondansetron hydrochloride use in children with gastroenteritis is increasing rapidly; however, little is known about its impact on outcomes. OBJECTIVE: To determine whether increasing emergency department ondansetron use has resulted in a reduction in intravenous rehydration rates. DESIGN, SETTING, AND PARTICIPANTS: Retrospective observational analysis of eligible visits included in the Pediatric Health Information System administrative database. Eligible institutions included 18 emergency departments geographically distributed across the United States, and participants included 804,000 patients aged 0 to 18 years who were diagnosed as having gastroenteritis in an emergency department at an eligible participating institution between January 1, 2002, and December 31, 2011. INTERVENTIONS: The presence or absence of oral ondansetron administration was identified for each patient through database review. Visits were categorized based on institutional ondansetron use: low (<5% administered ondansetron), medium (5%-25%), or high (>25%). MAIN OUTCOMES AND MEASURES: We conducted hospital-level analyses of the associations between ondansetron use and 3 outcomes: intravenous rehydration (primary), hospitalization, and emergency department revisits within 3 days. Time-series regression models were used, adjusting for demographic characteristics, laboratory testing, diagnostic imaging, and rotavirus infection. RESULTS: A total of 804,000 eligible patient visits were identified. Oral ondansetron use increased from a median institutional rate of 0.11% (interquartile range, 0.04%-0.44%) of patient visits in 2002 to 42.2% (interquartile range, 37.5%-49.1%) in 2011 (P < .001). Intravenous rehydration was administered to 43,413 of 232,706 children (18.7%) during the low ondansetron period compared with 59,450 of 334,264 (17.8%) during the high ondansetron period (adjusted percentage change = -0.33%; 95% CI, -1.86% to 1.20%). During the transition from low to high ondansetron use, we observed no change in the hospitalization rate (adjusted percentage change = -0.33%; 95% CI, -0.95% to 0.29%), but emergency department revisits decreased (adjusted percentage change = -0.31%; 95% CI, -0.49% to -0.13%). The change in all 3 outcomes varied widely between low and high ondansetron use categories at an institutional level. Oral ondansetron was provided to 13.5% (95% CI, 13.3% to 13.7%) of children administered intravenous rehydration. CONCLUSIONS AND RELEVANCE: Although ondansetron use increased during the study period, intravenous rehydration rates were unchanged. Most children administered intravenous fluids did not receive oral ondansetron. Our findings highlight the need to focus efforts to administer ondansetron to children at greatest risk for oral rehydration failure.
Authors: Paul L Aronson; Derek J Williams; Cary Thurm; Joel S Tieder; Elizabeth R Alpern; Lise E Nigrovic; Amanda C Schondelmeyer; Fran Balamuth; Angela L Myers; Russell J McCulloh; Evaline A Alessandrini; Samir S Shah; Whitney L Browning; Katie L Hayes; Elana A Feldman; Mark I Neuman Journal: J Hosp Med Date: 2015-08-06 Impact factor: 2.960
Authors: Elizabeth C Powell; Cindy G Roskind; David Schnadower; Cody S Olsen; T Charles Casper; Phillip I Tarr; Karen J O'Connell; Adam C Levine; Naveen Poonai; Suzanne Schuh; Alexander J Rogers; Seema R Bhatt; Serge Gouin; Prashant Mahajan; Cheryl Vance; Katrina Hurley; Ken J Farion; Robert E Sapien; Stephen B Freedman Journal: Ann Emerg Med Date: 2021-08-11 Impact factor: 6.762
Authors: Stephen B Freedman; Cindy G Roskind; Suzanne Schuh; John M VanBuren; Jesse G Norris; Phillip I Tarr; Katrina Hurley; Adam C Levine; Alexander Rogers; Seema Bhatt; Serge Gouin; Prashant Mahajan; Cheryl Vance; Elizabeth C Powell; Ken J Farion; Robert Sapien; Karen O'Connell; Naveen Poonai; David Schnadower Journal: Pediatrics Date: 2021-05-20 Impact factor: 9.703
Authors: Federico Marchetti; Maurizio Bonati; Alessandra Maestro; Davide Zanon; Francesca Rovere; Alberto Arrighini; Egidio Barbi; Paolo Bertolani; Paolo Biban; Liviana Da Dalt; Andrea Guala; Elisa Mazzoni; Anna Pazzaglia; Paolo Francesco Perri; Antonino Reale; Salvatore Renna; Antonio Francesco Urbino; Enrico Valletta; Antonio Vitale; Tiziana Zangardi; Antonio Clavenna; Luca Ronfani Journal: PLoS One Date: 2016-11-23 Impact factor: 3.240
Authors: Stephen B Freedman; Sajid B Soofi; Andrew R Willan; Sarah Williamson-Urquhart; Noshad Ali; Jianling Xie; Fady Dawoud; Zulfiqar A Bhutta Journal: Ann Emerg Med Date: 2018-11-02 Impact factor: 5.721
Authors: Naveen Poonai; Elizabeth C Powell; David Schnadower; T Charles Casper; Cindy G Roskind; Cody S Olsen; Phillip I Tarr; Prashant Mahajan; Alexander J Rogers; Suzanne Schuh; Katrina F Hurley; Serge Gouin; Cheryl Vance; Ken J Farion; Robert E Sapien; Karen J O'Connell; Adam C Levine; Seema Bhatt; Stephen B Freedman Journal: JAMA Netw Open Date: 2021-04-01