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Practice variation across five European paediatric emergency departments: a prospective observational study
Fabienne Ropers1, Patrick Bossuyt2, Ian Maconochie3
1Willem-Alexander Children's Hospital, department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
Insights
Paediatric emergency departments (EDs) show significant variation in diagnostic testing, treatment, and admission practices. These hospital-specific patterns persist across various pediatric conditions, suggesting underlying differences in healthcare delivery.
Area of Science:
- Pediatric Emergency Medicine
- Healthcare Management
- Comparative Health Services Research
Background:
- Paediatric emergency departments (EDs) are crucial for acute care.
- Variability in clinical practice can impact patient outcomes and resource utilization.
- Understanding practice variations is essential for quality improvement in paediatric healthcare.
Purpose of the Study:
- To compare paediatric healthcare practice variation among five European emergency departments (EDs).
- To analyze variability in diagnostic testing, treatment, and admission decisions.
- To identify hospital-specific patterns in paediatric emergency care management.
Main Methods:
- Prospective collection of data from consecutive paediatric visits in five European EDs across four countries.
- Analysis of management measures including lab testing, imaging, intravenous medication, and patient disposition.
- Multivariable logistic regression adjusted for patient characteristics and disease severity, comparing models with and without ED as a covariate.
Main Results:
- Data from 111,922 children were analyzed.
- Significant variability was observed in diagnostic testing, medication administration, and admission rates across EDs.
- Hospital-specific management patterns were consistent across different presenting complaints after adjusting for confounders.
Conclusions:
- Distinctive, hospital-specific patterns in paediatric ED management were identified.
- This variability suggests fundamental differences in healthcare practice influenced by organizational, professional, and systemic factors.
- Further research is needed to explore the drivers of these practice variations.
Objectives:
To compare paediatric healthcare practice variation among five European emergency departments (EDs) by analysing variability in decisions about diagnostic testing, treatment and admission.
Design And Population:
Consecutive paediatric visits in five European EDs in four countries (Austria, Netherlands, Portugal, UK) were prospectively collected during a study period of 9-36 months (2012-2015).
Primary Outcome Measures:
Practice variation was studied for the following management measures: lab testing, imaging, administration of intravenous medication and patient disposition after assessment at the ED.
Analysis:
Multivariable logistic regression was used to adjust for general patient characteristics and markers of disease severity. To assess whether ED was significantly associated with management, the goodness-of-fit of regression models based on all variables with and without ED as explanatory variable was compared. Management measures were analysed across different categories of presenting complaints.
Results:
Data from 111 922 children were included, with a median age of 4 years (IQR 1.7-9.4). There were large differences in frequencies of Manchester Triage System (MTS) urgency and selected MTS presentational flow charts. ED was a significant covariate for management measures. The variability in management among EDs was fairly consistent across different presenting complaints after adjustment for confounders. Adjusted OR (aOR) for laboratory testing were consistently higher in one hospital while aOR for imaging were consistently higher in another hospital. Iv administration of medication and fluids and admission was significantly more likely in two other hospitals, compared with others, for most presenting complaints.
Conclusions:
Distinctive hospital-specific patterns in variability of management could be observed in these five paediatric EDs, which were consistent across different groups of clinical presentations. This could indicate fundamental differences in paediatric healthcare practice, influenced by differences in factors such as organisation of primary care, diagnostic facilities and available beds, professional culture and patient expectations.
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