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Testing and Treatment Thresholds for Pediatric Pneumonia in the Emergency Department
Alexandra T Geanacopoulos1, James R Rudloff2, Sriram Ramgopal3
1Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.
Insights
Physician thresholds for pediatric community-acquired pneumonia (CAP) testing and treatment were identified. Knowledge of a prediction model lowered these thresholds, suggesting potential for improved clinical practice and model integration.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Decision Support
- Health Informatics
Background:
- Standardizing pediatric community-acquired pneumonia (CAP) management is crucial.
- Physician risk thresholds influence the implementation of clinical prediction models.
- Understanding these thresholds is key for effective tool integration into practice.
Purpose of the Study:
- To determine physician-derived thresholds for chest radiograph use and antibiotic treatment in pediatric CAP.
- To assess how knowledge of a validated prediction model impacts these physician thresholds.
Main Methods:
- Survey of pediatric emergency physicians using clinical vignettes.
- Assessment of testing and treatment decisions before and after providing model-estimated CAP probability.
- Logistic regression to define thresholds at 50% physician action probability.
Main Results:
- Physician testing and treatment thresholds for CAP were 17.6% and 66.1% before model knowledge.
- After model knowledge, thresholds decreased to 13.5% for testing and 58.0% for treatment.
- A significant shift in physician decision-making was observed with model-based probability.
Conclusions:
- Physician thresholds for pediatric CAP testing and treatment were successfully elucidated.
- Knowledge of a validated prediction model lowers physician thresholds, indicating potential for improved clinical practice.
- These findings can inform the development and integration of future pneumonia risk models.
Background:
Clinical prediction models for pediatric community-acquired pneumonia (CAP) may standardize management. Understanding physician risk thresholds is important for model implementation. We aimed to elucidate physician-derived thresholds for chest radiograph performance and empirical antibiotic treatment of CAP among children presenting to the emergency department with respiratory illness before and after knowledge of results of a validated clinical prediction model.
Methods:
Pediatric emergency physicians were surveyed through the American Academy of Pediatrics Pediatric Emergency Medicine Collaborative Research Committee and provided 8 clinical vignettes for children with respiratory symptoms. Respondents were asked to indicate their probability of radiographic CAP and choose whether they would obtain a chest radiograph or give empirical antibiotics before and after being provided with the probability of radiographic CAP based on a validated prediction model. We used logistic regression to establish testing and treatment thresholds, defined as the disease probability at which half of physicians acted.
Results:
Two-hundred and eight (44.3%) of 469 physicians completed the survey. Most were attending physicians (96.0%) practicing in a freestanding children's hospital (76.8%). Testing and treatment thresholds for CAP were 17.6% (95% confidence interval [CI] 16.4% to 18.8%) and 66.1% (95% CI 60.1% to 72.5%), respectively, before knowledge of the model-estimated probability. With knowledge of the prediction model, testing and treatment thresholds were 13.5% (95% CI 12.3% to 14.7%) and 58.0% (95% CI 53.2-62.8).
Conclusions:
We elucidated physician thresholds for testing and treatment of CAP, which may be integrated into future pneumonia risk models to improve acceptability and incorporation into practice.
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