Jonathan C Papic1, S Maria E Finnell2, Charles M Leys3, William E Bennett4, Stephen M Downs5. 1. Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. Electronic address: papi0011@umn.edu. 2. Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN. 3. Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. 4. Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN; Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN. 5. Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN; Regenstrief Institute, Inc, Indianapolis, IN.
Abstract
BACKGROUND: Rates of anti-reflux procedures (ARP) vary greatly among pediatric hospitals. How pediatric subspecialists make referral decisions for ARPs has not been described. The aim of this study was to characterize pediatric subspecialists' decision making for referring children for ARPs. METHODS: Pediatric subspecialists at a single children's hospital were interviewed about their decision making when referring for ARPs. Qualitative analysis was performed on clinicians' perceptions of the risks and benefits of the treatment options. Clinical algorithms were derived from each interview and were compared using the Clinical Algorithm Nosology. Clinical Algorithm Structural Analysis (CASA) scores were calculated to assess algorithm complexity. Clinical Algorithm Patient Abstraction (CAPA) scores on a scale from 0 (different) to 10 (identical) were generated based on algorithm agreement. RESULTS: The interviews yielded 15 algorithms. There was substantial variation in the providers' perceived risks and benefits of the treatment options. CASA scores ranged from 8 to 28 and CAPA scores ranged from 0 to 5.7 (median, 0), indicating great variation in both complexity and patient management. Management variation included testing (33% of algorithms incorporated pH probe test, 67% upper gastrointestinal, and 47% small bowel follow-through), procedure contraindications (33% considered history of gagging a contraindication to ARP), and use of gastrojejunostomy tubes (20% using gastrojejunostomy tube before ARP). CONCLUSION: No standards exist for the decision to refer children with gastroesophageal reflux disease for ARP. There is great variation among pediatric subspecialists in their decision making. Differences in providers' perception of the risks and benefits of these procedures contribute to this variation.
BACKGROUND: Rates of anti-reflux procedures (ARP) vary greatly among pediatric hospitals. How pediatric subspecialists make referral decisions for ARPs has not been described. The aim of this study was to characterize pediatric subspecialists' decision making for referring children for ARPs. METHODS: Pediatric subspecialists at a single children's hospital were interviewed about their decision making when referring for ARPs. Qualitative analysis was performed on clinicians' perceptions of the risks and benefits of the treatment options. Clinical algorithms were derived from each interview and were compared using the Clinical Algorithm Nosology. Clinical Algorithm Structural Analysis (CASA) scores were calculated to assess algorithm complexity. Clinical Algorithm Patient Abstraction (CAPA) scores on a scale from 0 (different) to 10 (identical) were generated based on algorithm agreement. RESULTS: The interviews yielded 15 algorithms. There was substantial variation in the providers' perceived risks and benefits of the treatment options. CASA scores ranged from 8 to 28 and CAPA scores ranged from 0 to 5.7 (median, 0), indicating great variation in both complexity and patient management. Management variation included testing (33% of algorithms incorporated pH probe test, 67% upper gastrointestinal, and 47% small bowel follow-through), procedure contraindications (33% considered history of gagging a contraindication to ARP), and use of gastrojejunostomy tubes (20% using gastrojejunostomy tube before ARP). CONCLUSION: No standards exist for the decision to refer children with gastroesophageal reflux disease for ARP. There is great variation among pediatric subspecialists in their decision making. Differences in providers' perception of the risks and benefits of these procedures contribute to this variation.
Authors: Jason H Wasfy; Michael K Hidrue; Robert W Yeh; Katrina Armstrong; G William Dec; Eugene V Pomerantsev; Michael A Fifer; Timothy G Ferris Journal: J Am Heart Assoc Date: 2015-10-16 Impact factor: 5.501