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Large Variation in Clinical Practice amongst Pediatricians in Treating Children with Recurrent Abdominal Pain

Michael W van Kalleveen¹, Elise J Noordhuis¹, Carole Lasham¹

¹Department of Pediatrics, Tergooi Hospital, Blaricum, the Netherlands.

Pediatric Gastroenterology, Hepatology & Nutrition

|May 22, 2019

Insights

Pediatricians show high variability in diagnosing recurrent abdominal pain (RAP) in children, with only moderate adherence to clinical guidelines. This highlights inconsistencies in pediatric care for RAP.

Area of Science:

Pediatric Gastroenterology
Clinical Practice Variability
Diagnostic Accuracy

Background:

Recurrent abdominal pain (RAP) is a common pediatric complaint.
Variability in diagnostic approaches can impact patient outcomes.
Standardized care pathways are crucial for effective management.

Purpose of the Study:

To assess variability among pediatricians in diagnosing RAP in children aged 4-18.
To evaluate adherence to national guidelines in RAP management.
To quantify intra- and inter-observer variability in diagnostic work-ups.

Main Methods:

Retrospective cohort study comparing pediatricians' diagnostic work-ups to national guidelines.
Cramer's V test used to measure intra- and inter-observer variability.
Prospective evaluation using a fictitious case to assess diagnostic consistency.

Main Results:

High inter-observer variability (very weak association, 0.22) and moderate intra-observer variability (0.35-0.46) were observed.
Guideline adherence was 66.8%.
Prospective case analysis showed a moderately strong association (Cramer's V=0.60), suggesting improved consistency.

Conclusions:

Significant intra- and inter-observer variability exists in pediatricians' management of RAP.
Guideline adherence is moderate, indicating room for improvement in clinical practice.
Standardized diagnostic approaches are needed to reduce variability in pediatric RAP care.

Read full analysis

Abstract

Purpose:

To evaluate intra- and inter-observer variability and guideline adherence amongst pediatricians in treating children aged between 4 and 18 years referred with recurrent abdominal pain (RAP) without red flags.

Methods:

The first part of the study is a retrospective single-center cohort study. The diagnostic work-ups of eight pediatricians were compared to the national guidelines. Intra- and inter-observer variability were examined by Cramer's V test. Intra-observer variability was defined as the amount of variation within a pediatrician and inter-observer variability as the amount of variation between pediatricians in the application of diagnostic work-up in children with RAP. Prospectively, the same pediatricians were requested to provide a report on their management strategy with a fictitious case to prove similarities in retrospective diagnostic work-up.

Results:

A total of 10 patients per pediatrician were analyzed. Retrospectively, a (very) weak association between pediatricians' diagnostic work-ups was found (0.22), which implies high inter-observer variability. The association between intra-observer diagnostic was moderate (range, 0.35-0.46). The Cramer's V of 0.60 in diagnostic work-up between pediatricians in the fictitious case implied the presence of a moderately strong association and lower inter-observer variability than in the retrospective study. Adherence to the guideline was 66.8%.

Conclusion:

We found a high intra- and inter-observer variability and moderate guideline adherence in daily clinical practice amongst pediatricians in treating children with RAP in a teaching hospital.

Keywords:

Abdominal pain Guideline adherence Interobserver variability Intra-observer variability Pediatricians

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