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Referring physicians' decision making for pediatric anti-reflux procedures
Jonathan C Papic1, S Maria E Finnell2, Charles M Leys1
1Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN.
Insights
Pediatric subspecialists show significant variation in referring children for anti-reflux procedures (ARP). Differences in perceived risks and benefits of treatment options contribute to inconsistent patient management and a lack of standardized care for gastroesophageal reflux disease.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Clinical Decision Making
Background:
- Referral rates for anti-reflux procedures (ARP) vary significantly across pediatric healthcare facilities.
- The decision-making processes of pediatric subspecialists regarding ARP referrals remain largely undescribed.
- This study aimed to elucidate how pediatric subspecialists decide on referring patients for ARPs.
Purpose of the Study:
- To characterize the decision-making patterns of pediatric subspecialists when referring patients for anti-reflux procedures.
- To identify factors influencing subspecialists' choices regarding surgical intervention for gastroesophageal reflux disease (GERD).
Main Methods:
- Qualitative interviews were conducted with pediatric subspecialists at a single children's hospital.
- Clinicians' perceptions of risks and benefits associated with treatment options were analyzed.
- Clinical algorithms were derived, compared using the Clinical Algorithm Nosology, and assessed for complexity (CASA) and agreement (CAPA).
Main Results:
- Fifteen distinct clinical algorithms were identified, demonstrating substantial variability in perceived risks and benefits.
- Clinical Algorithm Structural Analysis (CASA) scores ranged from 8 to 28, and Clinical Algorithm Patient Abstraction (CAPA) scores ranged from 0 to 5.7, indicating significant variation in complexity and patient management.
- Management differences included diagnostic testing utilized (pH probe, upper GI, small bowel follow-through), contraindications considered (e.g., gagging history), and the use of gastrojejunostomy tubes prior to ARP.
Conclusions:
- There is a notable absence of standardized guidelines for referring pediatric patients with GERD for ARP.
- Significant heterogeneity exists among pediatric subspecialists in their decision-making processes for ARP referrals.
- Discrepancies in perceived procedural risks and benefits among providers are key drivers of this clinical 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.
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