Trends in Management of Children With Acute Gastroenteritis in US Emergency Departments.

Introduction

Acute gastroenteritis (AGE) is a common reason for emergency department (ED) visits and hospitalizations for children.[1] Recommendations emphasize oral rehydration therapy (ORT) for children with AGE and mild to moderate dehydration, and intravenous rehydration for those with severe dehydration or in whom ORT fails.[2] Intravenous rehydration is associated with longer hospital stays, return visits, adverse events, costs, and pain. Oral ondansetron reduces vomiting, the need for intravenous rehydration, and hospitalizations; however, benefits are limited to children with evidence of dehydration.[3] Reducing unnecessary interventions and admissions is crucial to optimizing outcomes. Given the high prevalence and costs associated with AGE treatment for children, understanding national trends in management in a broad, generalizable sample is important.

Methods

This repeated cross-sectional analysis used data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) ED database from January 1, 2006, to December 31, 2018, undertaken following release (June 2021). The NHAMCS is conducted annually using multistage probability sampling of approximately 30 000 ED visits in the US to generate nationally representative, population-level estimates.[4] We analyzed visits for patients younger than 18 years with had a primary discharge diagnosis of AGE or a primary diagnosis of nausea, vomiting, diarrhea, or dehydration and a secondary diagnosis of AGE (eTable in the Supplement), as described previously.[5] Discharge diagnoses were identified using ICD-9-CM (2006-2015) and ICD-10-CM (2016-2018) codes. Patient- and ED-level variables were extracted, including diagnostic testing and treatments. Survey-weighting procedures were applied to estimate annual proportions. Trends were analyzed using a weighted Pearson χ2 test of proportions (Stata, version 14.1; StataCorp LLC). A 2-tailed P < .05 was considered significant. This study was exempted from review by the McGill University Health Centre Research Ethics Board because the NHAMCS data are deidentified and publicly available. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Results

The NHAMCS contained 81 757 unweighted ED visits for pediatric patients between 2006 and 2018; 4122 patients (mean age, 4.8 years; 95% CI, 4.6-5.1 years) met inclusion criteria, representing an estimated 19.87 million (95% CI, 17.74 to 22.01 million) visits for children with AGE (Table). Most visits were to nonacademic (84.9%; 95% CI, 81.4%-87.8%) and nonpediatric (80.4%; 95% CI, 74.7%-85.1%) EDs. Visits for AGE increased over time (2006: 1.23 million; 95% CI, 1.01-1.46; 2018: 1.87 million; 95% CI, 1.29-2.45; P = .03 for trend) (Figure) and as a proportion of all ED visits by children (2006: 4.7%; 95% CI, 4.1%-5.4%; 2018: 5.6%; 95% CI, 4.6%-6.7%; P = .02 for trend). Ondansetron administration increased from 10.6% (95% CI, 7.0%-15.7%) to 59.2% (95% CI, 52.0%-66.1%; P < .001 for trend). Intravenous rehydration and hospitalizations were both unchanged over time (28.2% and 4.8% in 2018, respectively). Ondansetron was administered to 53.9% (95% CI, 49.4%-58.3%) of children who received intravenous fluids and 49.1% (95% CI, 35.7%-62.6%) of those hospitalized.

Table.

Characteristics and Outcomes Among Children With AGE Presenting to US EDs, 2006-2018

Characteristic or outcome	Unweighted observations, No.	Population estimate, in millions (95% CI)	Overall weighted visits, % (95% CI)
Visits
Total ED visits by children with AGE	4122	19.87 (17.74-22.00)	5.1 (4.9-5.4)a
AGE with nausea and vomiting	2774	14.0 (12.4-15.6)	70.6 (68.4-72.7)
Age group, yb
0-<3	1977	9.32 (8.20-10.43)	46.9 (44.3-49.5)
3-<13	1663	8.14 (7.17-9.11)	41.0 (38.8-43.1)
13-<18	482	2.41 (2.01-2.82)	12.1 (10.7-13.8)
Sex
Female	2011	9.81 (8.59-11.02)	49.4 (46.9-51.8)
Male	2111	10.07 (8.94-11.19)	50.7 (48.2-53.1)
Race
Black	1065	5.17 (4.26-6.07)	26.0 (23.1-29.2)
White	2758	13.62 (12.13-15.11)	68.6 (65.3-71.6)
Otherc	299	1.08 (0.84-1.33)	5.5 (4.4-6.7)
Insurance provider
Medicaid or Medicare	2448	11.80 (10.18-13.42)	59.4 (56.1-62.6)
Private	1095	4.99 (4.39-5.58)	25.1 (22.9-27.5)
Self-pay	225	1.13 (0.89-1.37)	5.7 (4.6-7.0)
Other or unknown	354	1.96 (1.46-2.45)	9.9 (7.8-12.5)
Triage acuity level
Immediate or emergency	208	0.83 (0.64-1.02)	4.2 (3.4-5.2)
Urgent	1695	8.04 (7.09-8.99)	40.5 (37.6-43.4)
Semiurgent	1234	6.09 (5.26-6.92)	30.7 (28.0-33.5)
Nonurgent	239	0.99 (0.71-1.27)	5.0 (3.8-6.4)
Unknown or unavailable	746	3.93 (3.06-4.79)	19.8 (16.5-23.4)
Type of institutiond
Pediatric	787	3.89 (2.68-5.10)	19.6 (14.9-25.3)
Nonpediatric	3335	15.98 (14.23-17.73)	80.4 (74.7-85.1)
Teaching	826	3.00 (2.30-3.71)	15.1 (12.2-18.6)
Nonteaching	3296	16.87 (14.92-18.82)	84.9 (81.4-87.8)
Diagnostic testing
Any blood investigations	1308	6.15 (5.39-6.91)	30.9 (28.5-33.5)
Any diagnostic imaging	669	3.63 (3.05-4.22)	18.3 (16.4-20.3)
Ondansetron use
ED administration	1581	8.85 (7.59-10.11)	44.6 (41.5-47.7)
Intravenous rehydration
Overall	1077	5.19 (4.56-5.83)	26.1 (24.1-28.3)
Received ED ondansetron	516	2.80 (2.35-3.24)	53.9 (49.4-58.3)
Hospitalization
Overall	146	0.65 (0.46-0.84)	3.3 (2.5-4.3)
Received ED ondansetron	55	0.32 (0.18-0. 46)	49.1 (35.7-62.6)

Abbreviations: AGE, acute gastroenteritis; ED, emergency department.

Percentage of all visits for patients younger than 18 years in the National Hospital Ambulatory Medical Care Survey (NHAMCS).

Mean age of 4.8 years (95% CI, 4.6-5.1 years).

The race variable is captured by NHAMCS site representatives as 1 of the following: White, Black/African American, Asian, Native Hawaiian/other Pacific Islander, American Indian/Alaska Native, or more than 1 race reported. The NHAMCS then recategorizes race as White, Black, or other. The recategorized race variable was used for the analyses of this study.

Emergency departments were classified as pediatric hospitals if 85% or more of all visits were for patients younger than 21 years and classified as teaching hospitals if 25% or more of all patients were evaluated by a resident physician.

Figure.

Annual Trends in US Emergency Department (ED) Visits, Ondansetron Use, Intravenous Rehydration, and Hospitalizations for Children With Acute Gastroenteritis (AGE), 2006-2018

Discussion

In a generalizable sample of US ED visits from 2006 to 2018, ondansetron use for children with AGE increased markedly, with no observed decrease in intravenous rehydration or hospitalizations. Approximately half of children administered intravenous fluids or hospitalized did not receive ondansetron, suggesting that many children without dehydration receive ondansetron with limited benefit, whereas those most likely to benefit receive intravenous fluids without an adequate trial of ondansetron and ORT. Because ED visits for children with AGE are increasing, knowledge translation initiatives are urgently needed to optimize ondansetron use and reduce excessive use of intravenous fluids. Ondansetron-supported ORT for appropriately selected children can achieve intravenous rehydration rates of 9%,[6] more than 3-fold lower than 2018 national estimates.

This study has limitations. The NHAMCS does not contain detailed patient-level information, such as dehydration severity, and longitudinal analysis of return visits is not possible. Route of medication administration is not recorded; thus, lack of benefit from ondansetron may reflect children receiving intravenous ondansetron and fluids concomitantly. Misclassification is possible; however, the NHAMCS database is rigorously quality-controlled.[4]