Setting‐based Practice Variation in the Management of Simple Febrile Seizure

Abstract

Abstract. Objective: To identify provider-based differences in the ED assessment and management of children presenting with uncomplicated, first-time febrile seizures. Methods: Multicenter, retrospective cohort study of seven EDs in the Chicago area: two tertiary academic pediatric EDs (PEDs) and five community-based general EDs (GEDs). The visits of all patients with a discharge diagnosis including the term ''seizure'' were identified from a 30-month period. Records of patients who met criteria for simple, first-time febrile seizure were reviewed (age 6-60 months; temperature Ն38.0ЊC; single, generalized, tonic-clonic seizure <20 minutes; ''alert'' or ''arousable'' on presentation; absence of known neurologic disease). Results: Four hundred fifty-five records were included: 330 and 125 patients presenting to GEDs and PEDs, respectively. The two groups did not differ in mean age, vital signs, reported duration of seizure, or prior antibiotic use. Lumbar puncture (LP) was performed more often in the GED group (33% vs 22%). No patients were found to have bacterial meningitis. The patients in the GED group were more likely to receive parenteral antibiotics in the ED (56% vs 22%) and to be admitted or transferred (18% vs 4%). In a logistic regression model incorporating age, temperature, seizure duration, seizure in the ED, prior antibiotic use, primary care, and insurance status, the GED patients remained more likely to have an LP (OR 1.5), receive parenteral antibiotics (OR 2.5), and be admitted or transferred (OR 2.5). Conclusions: There were significant setting-based differences in the evaluation and management of children with simple febrile seizures presenting to GEDs and PEDs. Key words: practice variation; emergency department; febrile seizure; pediatrics. ACADEMIC EMERGENCY MEDICINE 2000; 7:21-27 L ONGITUDINAL studies estimate that 2-4% of all children experience a febrile seizure before their fifth birthdays. 1,2First-time simple febrile seizures carry a benign prognosis, and extensive neurodiagnostic evaluation is seldom necessary.3-6 Such children often present to the nearest ED and are managed by practitioners with varying levels of pediatric training and experience. We hypothesized that an examination of actual clinical practice would reveal significant variation METHODSStudy Design. This was a retrospective cohort study of the ED management of simple febrile seizure. The two cohorts examined were children presenting to pediatric EDs (PEDs) and those arriving at general EDs (GEDs). Independent variables included patient clinical and demographic characteristics. The outcomes of interest were ED assessment and management decisions, including diagnostic testing, medication administration, and final disposition. The study protocol was distributed to, and approved by, the investigational review board at each institution.Study Setting and Population. Seven EDs in the Chicago area participated in this study. Five other EDs were initially approached, but were subsequently excluded: two lacked the capabilit...

Quality Indicators for High Acuity Pediatric Conditions

“…48 However, applying measures only to institutions with a particular volume of high acuity cases would miss a significant portion of patients who are seen in smaller centers, and it is in these centers where practice variation and the potential for improvement may be greatest. 21,[24][25][26]49 Many of the indicators developed here would be useful even for smaller volume centers for local quality improvement initiatives, such as measuring the impact of a new clinical pathway. Another solution already in use by the US Department of Health and Human Services is to aggregate data over 3 years.…”

“…[16][17][18] Evidence indicates that there is substantial practice variation for pediatric patients among emergency care providers, and that many providers do not optimally manage seriously injured or ill children. [19][20][21] Most of the recent work on practice variation and lack of adherence to practice guidelines in the pediatric ED setting has been done on common, often lower acuity conditions, [21][22][23][24][25][26] despite evidence of a similar gap between knowledge and practice in severely ill and injured children. 20 Identifying gaps in care for high acuity conditions, where improvement is likely to have the largest impact on quality of life and longevity, 19 requires valid and reliable quality indicators.…”

Differences in Admission Rates of Children With Bronchiolitis by Pediatric and General Emergency Departments

“…Several studies have been published, however, that examine differences between pediatric and general emergency departments in the management of bronchiolitis and, as well, several other diseases. [47][48][49][50][51][52][53] Although several studies used surveys to assess opinions regarding various management strategies, [47][48][49] some also used a retrospective methodology to establish actual differences in practice patterns between pediatric and general emergency physicians. 50 -53 In general, retrospective studies are thought to provide poorer quality data than that obtained from a prospective study design.…”

Variation in Emergency Department Admission Rates in US Children’s Hospitals

“…3 We were also unable to further examine factors that might contribute to variation in admission rates, including hospital-and physician-level characteristics, because these are not consistently available in the PHIS database. We could not examine the appropriateness of hospitalization for a given patient because we were unable to ascertain the outcomes for patients who were admitted versus those who were discharged.…”

“…1 Similarly, substantial variation has been demonstrated in the diagnostic testing, treatment, and disposition of children presenting with a variety of other conditions, including gastroenteritis, asthma, headache, and febrile seizures. [2][3][4][5][6] Some of the variation in care may be related to patientlevel differences in clinical presentation as well as to hospital-level factors, such as local availability of primary care physicians, hospital occupancy, or access to certain health care services. [7][8][9] The wide variation in clinical management raises concerns about whether every patient is receiving the optimal care and whether the lack of a standardized approach is contributing to unnecessary health care costs.…”