Practice Variations Between Emergency Medicine and Pediatric Physicians in the Treatment of URIs

1
Practice Variations Between Emergency Medicine
and Pediatric Physicians in the Treatment of URIs

• Nicole Colucci, DO, MAAP
• Resident, Emergency Medicine
• Resurrection Medical Center

2
Study Team

• Author and Co-investigators
• Mary Frances Kordick, MBA, PhD, RN, CNAA,BC
• Shu Chan, MD, MS, FACEP
• We are indebted to
• All Survey Respondents

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INTRODUCTION/BACKGROUND

• High prevalence of URIs seen in the emergency
  department
• Most common cause of illness in children
• Overuse of unnecessary antimicrobials
• Increasing antimicrobial resistance patterns

Sources Ipp M, Carson S, Petric M, Parkin PC.
Rapid painless diagnosis of viral respiratory
infection. Arch Dis Child 2002 86(5)372-373.
Jacobs RF. Judicious use of antibiotics for
common pediatric respiratory infections. Pediatr
Infect Dis J 2000 19(9)938-943.
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STUDY OBJECTIVE

• Examine practice variations between emergency
  medicine and pediatric physicians focusing on
• The diagnosis and management of children with
  respiratory signs/ symptoms
• Specifically, URIs

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CLINICAL RELEVANCE

• Reduce future resistance to antibiotics
• Monetary impact
• Identify future areas for improving education to
  physicians
• All previous studies evaluate pediatricians

Sources Jacobs RF. Judicious use of antibiotics
for common pediatric respiratory infections.
Pediatr Infect Dis J 2000 19(9)938-943.Boccazzi
A, Noviello S, Tonelli P, Coi P, Esposito S,
Carnelli V. The decision-making process in
antibacterial treatment of pediatric upper
respiratory infections A national prospective
office-based observational study. Int J Infect
Dis 2002 6(2)103-107.
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STUDY DESIGN

• Following acceptance by the IRB, a 22-item
  questionnaire focusing on the diagnosis and
  management of children(e-mailed to all members listed in directories of
  SAEM and the AAP-subsection of pediatric
  emergency medicine
• A cover letter explaining the survey was sent
  with a hyperlink to the web-based survey site
  (Formsite.com)
• Repeat e-mails were sent at weeks 3-4 after the
  initial mailing

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SURVEY QUESTIONS

• Do you utilize the diagnosis of upper respiratory
  infection (URI)?
• Is there an age in which URI is not an
  appropriate diagnosis?
• If you answered yes to the previous question,
  choose your age criterion?
• Do you document pulse oximetry in children with
  respiratory symptoms?

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SURVEY QUESTIONS

• Is there an age criterion in which you always
  order a CXR to exclude evidence of pneumonia or
  other pathology?
• Is there a season in which you order a CXR more
  frequently?
• Do you prescribe or recommend medications when
  you diagnose URI?
• If you did not intend to provide a prescription
  for medication and the parent requests an
  antibiotic, what describes your most frequent
  action?

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DATA ANALYSIS

• Data downloaded from Formsite.com
• Descriptive and chi-square statistics were
  completed using the Statistical Package for
  Social Sciences for Windows Version 11.5

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RESULTS

• 3739 e-mails sent via two separate mailings
• Response Rate 26.3, N728
• Population
• EM physicians, 73.8 (n 539)
• Pediatric EM physicians, 24.0 (n 175)
• Remainder non-physician practitioners and
  eliminated from the study

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DEMOGRAPHICS

• Similar for both groups
• Gender Male-70.3
• Board eligibility/certification 81-84
• Primary site of practice Urban/Academic Medical
  Centers
• Different between the groups of physicians
• Pediatric population of patients seen
• EM-25
• PEM-75-100

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RESULTS

• EM physicians are more likely to confine the
  diagnosis of URI to certain age groups (EM-49.9
  vs PEM-29.1 P0.000)
• 8 years old
• Both groups agree that URI is an inappropriate
  diagnosis in children
• PEM are less likely to use antibiotics,
  decongestants or antihistamines for treatment in
  pediatric URIs (next slide)
• Saline drops, antipyretics

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RESULTS
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DISCUSSION

• Pulse oximetry should be the fifth vital sign in
  children with respiratory signs/symptoms
• Inexpensive
• Diagnose mild to moderate hypoxia unsuspected by
  physical exam
• CXR should be ordered on children with
  respiratory signs/symptoms
• 0-3 months age, abnormal SaO2, occult fever
  work-up

Sources Mower WR, Sachs C, Nicklin EL, Baraff
LJ. Pulse oximetry as a fifth pediatric vital
sign. Pediatrics 1997 99(5)681-686. Baraff LJ.
Management of fever without source in infants and
children. Ann Emerg Med 2000 36(6)602-614.
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DISCUSSION

• Multiple sources agree that the most common cause
  of URIs is viral and has no indication for
  antibiotics
• Studies on the efficacy of the use of
  antihistamines, cough suppressants and mucolytics
  in the treatment of URIs do not change the
  course of the illness

Sources Morikawa M. Upper respiratory infection
in acute pediatric care in internal conflict,
Kosovo, 1999. J Trop Pediatr 2001 47(6)379-382.
Nambiar S, Schwartz RH, Sheridan MJ. Are
pediatricians adhering to principles of judicious
antibiotic use for upper respiratory tract
infections? South Med J 2002 95(10)1163-1167.
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LIMITATIONS

• Survey response rate of 26.3 with two mailings
• Allow for a third mailing
• Limited population
• Utilize more databases(ACEP, SAEM, AAP)
• Unable to clearly define specific prescribing
  patterns of antibiotics/ decongestants
• More precise questions
• No specific definition for URI

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CONCLUSIONS

• Practice differences exist between emergency
  medicine and pediatric emergency medicine
  physicians
• Areas for additional education in both groups of
  physicians
• Indications for diagnostic tests
• Lack of indication for antibiotics in the
  treatment of viral URIs
• Use of supportive care as treatment for URIs
• Allowing the physician to offer non-medication
  options to caregivers