Referring physicians' decision making for pediatric anti-reflux procedures

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.