Practice Pattern Variation in Test Ordering for Low-Acuity Pediatric Emergency Department Patients

Pediatric Emergency Care - Tập 37 Số 3 - Trang e116-e123 - 2021
Kaynan Doctor, Kristen Breslin, James M. Chamberlain, Deena Berkowitz

Tóm tắt

Objectives Rising costs in healthcare have focused attention on interventions to optimize efficiency of patient care, including decreasing unnecessary diagnostic testing. The primary objective of this study was to determine the variability of laboratory and radiology testing among licensed independent providers (LIPs) with different training backgrounds treating low-acuity patients in a pediatric emergency department (PED). Methods We performed a retrospective review of the electronic health records of all encounters with patients 21 years or younger, triaged as low-acuity, visiting 2 urban, academic PEDs from January 2012 to December 2013. We calculated frequency of orders for specific tests, including complete blood counts, aerobic blood cultures, urine cultures, and chest radiographs. Bivariable analyses were used to measure associations of test ordering between these LIP dyad groups: physician versus nurse practitioner (NP); physicians with pediatric emergency medicine fellowship training (PEM) versus physicians without PEM training and physicians with at least 5 years since residency graduation versus less than 5 years. We used multivariable logistic regression to adjust for potential confounders, including ED location, trainee co-management, and patient characteristics. We also performed sensitivity analyses by location. Results There were 148,570 total encounters treated by 12 NPs and 144 physicians, of whom 60 were PEM physicians. Seventy-three physicians had 5 or more years of experience. Testing rates per patient encounter ranged from 0% to 40% for individual providers. In bivariable analyses, testing was more likely when the LIP was a physician (odds ratio [OR] = 1.2, 95% confidence interval = 1.1–1.2) or PEM trained (OR = 1.3, 1.2–1.3). In multivariable analyses, testing was more likely for encounters with PEM providers (adjusted OR [AdjOR] = 1.2, 1.1–1.3). A sensitivity analysis on a subset of encounters seen exclusively at our PED-based urgent care revealed that testing was also more likely for encounters seen by PEM physicians (AdjOR = 1.5, 1.4–1.7) and with NPs (AdjOR = 1.2, 1.1–1.4) compared with physicians. Conclusions Our study identified substantial variation in test ordering patterns for LIPs treating low-acuity patients. There were significant differences in ordering practices between providers from different training backgrounds, most significantly when comparing PEM with non-PEM providers. Further research should examine interventions to standardize practice across disciplines.

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Tài liệu tham khảo

2004, Overcrowding crisis in our 382 nation's emergency departments: is our safety net unraveling?, Pediatrics, 114, 878, 10.1542/peds.2004-1287

2007, Quality of primary care and subsequent pediatric emergency department utilization, Pediatrics, 119, 1131, 10.1542/peds.2006-3518

2001, Safety net research in emergency medicine: proceedings of the Academic Emergency Medicine Consensus Conference on “The Unraveling Safety Net”, Acad Emerg Med, 8, 1024, 10.1111/j.1553-2712.2001.tb01110.x

2012, Emergency Severity Index version 4: a valid and reliable tool in pediatric emergency department triage, Pediatr Emerg Care, 28, 753, 10.1097/PEC.0b013e3182621813

2001, When the visit to the emergency department is medically nonurgent: provider ideologies and patient advice, Qual Health Res, 11, 161, 10.1177/104973201129119028

2013, Primary care spatial density and nonurgent emergency department utilization: a new methodology for evaluating access to care, Acad Pediatr, 13, 278, 10.1016/j.acap.2013.02.006

2002, Usual source of care and nonurgent emergency department use, Acad Emerg Med, 9, 916, 10.1197/aemj.9.9.916

1997, Societal savings by “fast tracking” lower acuity patients in an urban pediatric emergency department, Am J Emerg Med, 15, 551, 10.1016/S0735-6757(97)90154-6

2010, Demographics of patient visits during high daily census in a pediatric ED, Am J Emerg Med, 28, 56, 10.1016/j.ajem.2008.09.035

1996, Ambulatory visits to hospital emergency departments. Patterns and reasons for use. 24 Hours in the ED Study Group, JAMA, 276, 460, 10.1001/jama.1996.03540060036032

2002, “Crossing the Quality Chasm” in emergency medicine, Acad Emerg Med, 9, 1074, 10.1197/aemj.9.11.1074

2014, Reducing catheter-associated urinary tract infections: a quality-improvement initiative, Pediatrics, 134, e857, 10.1542/peds.2013-3470

2013, Variability in the emergency department use of discretionary radiographs in children with common respiratory conditions: the mixed effect of access to pediatrician care, CJEM, 15, 8, 10.2310/8000.2012.120649

2013, Decreasing radiation exposure on pediatric portable chest radiographs, Radiol Technol, 85, 9

2012, Effect of testing and treatment on emergency department length of stay using a national database, Acad Emerg Med, 19, 525, 10.1111/j.1553-2712.2012.01353.x

1981, Use of diagnostic services by physicians in community practice, Med Care, 19, 297, 10.1097/00005650-198103000-00005

1996, Effect of health care system factors on test ordering, Arch Pediatr Adolesc Med, 150, 1154, 10.1001/archpedi.1996.02170360044006

1993, Diagnostic test ordering in the evaluation of febrile children. Physician and environmental factors, Am J Dis Child, 147, 870, 10.1001/archpedi.1993.02160320072022

1985, Physician characteristics and organizational factors influencing use of ambulatory tests, Med Decis Making, 5, 401, 10.1177/0272989X8500500402

2007, Non-evidence-based variables affecting physicians' test-ordering tendencies: a systematic review, Neth J Med, 65, 167

1984, The effects of physicians' training and personality on test ordering for ambulatory patients, Am J Public Health, 74, 1271, 10.2105/AJPH.74.11.1271

2005, Emergency physicians' fear of malpractice in evaluating patients with possible acute cardiac ischemia, Ann Emerg Med, 46, 525, 10.1016/j.annemergmed.2005.04.016

2013, Variation in pediatric care at US hospitals, Pediatrics, 132, 369, 10.1542/peds.2013-1569

2007, Emergency Severity Index version 4: clarifying common questions, J Emerg Nurs, 33, 182, 10.1016/j.jen.2006.11.009

2014, Evaluation of an after-hours call center: are pediatric patients appropriately referred to the emergency department?, Pediatr Emerg Care, 30, 798, 10.1097/PEC.0000000000000262

2013, Variation in emergency department diagnostic testing and disposition outcomes in pneumonia, Pediatrics, 132, 237, 10.1542/peds.2013-0179

2009, Pediatric emergency department overcrowding: electronic medical record for identification of frequent, lower acuity visitors. Can we effectively identify patients for enhanced resource utilization?, J Emerg Med, 36, 311, 10.1016/j.jemermed.2007.10.090

2006, When overcrowding paralyzes an emergency department, Manag Care, 15, 54

2013, The effect of medical students and residents on measures of efficiency and timeliness in an academic medical center emergency department, Acad Med, 88, 1723, 10.1097/ACM.0b013e3182a7f1f8

2014, Variation in emergency department admission rates in US children's hospitals, Pediatrics, 134, 539, 10.1542/peds.2014-1278

1996, Disagreement among health care professionals about the urgent care needs of emergency department patients, Ann Emerg Med, 28, 474, 10.1016/S0196-0644(96)70108-7

2016, The development and evaluation of an evidence-based guideline programme to improve care in a paediatric emergency department, Emerg Med J, 33, 109, 10.1136/emermed-2014-204363

1986, Relationship of beliefs and behavior in test ordering, Am J Med, 80, 865, 10.1016/0002-9343(86)90630-3

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Pediatric Emergency Care

Tập 37 Số 3

e116-e123

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