Practice variation across five European paediatric emergency departments: a prospective observational study

Abstract

ObjectivesTo compare paediatric healthcare practice variation among five European emergency departments (EDs) by analysing variability in decisions about diagnostic testing, treatment and admission.Design and populationConsecutive 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 measuresPractice variation was studied for the following management measures: lab testing, imaging, administration of intravenous medication and patient disposition after assessment at the ED.AnalysisMultivariable 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.ResultsData 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.ConclusionsDistinctive 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.

Diagnostic testing in children: A qualitative study of pediatricians' considerations

“…Some pediatric studies reported on practice variation of diagnostic test use, 30,31 overtesting 32 and effects of interventions to promote appropriate testing, 33,34 but an overview of the spectrum of considerations relevant to test decisions in pediatrics is lacking.…”

“…These studies were predominantly performed in adult medicine and have resulted in several proposed frameworks for testing and overtesting. 10, [23][24][25][26][27][28][29] Some pediatric studies reported on practice variation of diagnostic test use, 30,31 overtesting 32 and effects of interventions to promote appropriate testing, 33,34 but an overview of the spectrum of considerations relevant to test decisions in pediatrics is lacking.…”