Original Contribution
Practice variation in the management for nontraumatic pediatric patients in the ED

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Abstract

Study objective

To improve the management quality and monitoring for common pediatric illnesses in the general emergency department (ED), we examined the effect of physician specialty training on medical resource use and patient outcomes.

Methods

This was a retrospective cohort review of visits by children less than 18 years to the ED of 2 university-affiliated teaching hospitals. Clinical management by 2 groups (emergency physicians [EPs] and pediatricians each working 168 h/wk) was compared with respect to demographics, ED resource use, short-term outcome, disposition, direct ED costs for each visit, and frequency of radiographic and laboratory test use. The effects of medical decision making on resource use was assessed by comparing costs of radiographic studies, laboratory studies, and medication.

Results

Between-group differences in mean patient age, sex, and triage category were insignificant. Compared to pediatricians, EPs used radiographic and laboratory studies more frequently (respectively, 10.1% and 3.8% higher frequency and 90.5% and 7.6% higher cost) and less medication (12.5% lower cost). Patients managed by EPs had longer ED length of stay (LOS), higher admission rates to general wards, and shorter LOS per hospitalization but similar 72-hour revisit rates, needed more frequent referral for medical reasons, and left more frequently against medical advice.

Conclusion

Emergency physicians spent more time and medical resources and admitted patients at a higher rate. Emergency physicians and pediatricians managed critical patients similarly.

Introduction

Emergency physicians (EPs) and pediatricians often have significantly different training and practice settings. Their management of pediatric patients with common illnesses can be different [1], [2], [3]. These differences affect emergency department (ED) length of stay (LOS), ED cost, use of medical resources, and patient outcomes [4]. Previous studies examining unique diseases or diagnoses have found variations in clinical practice between EPs and pediatricians in pediatric EDs [1], [2], [3], [5]. However, few articles mention the differences in the management of emergency pediatric patients between EPs and pediatricians on the basis of extensive evaluation of demographics, variable diagnoses, use of medical resources, dispositions, and short-term outcome in the ED. Most nontrauma pediatric patients in Taiwan are evaluated in a separate part of the general ED. In this setting, 2 specialists treat pediatric patients as follows: EPs who treat patients of all ages, mainly adults, and pediatricians, who treat children only. Our previous study demonstrated that treatment by pediatric residents and attending physicians in the ED resulted in similar short-term outcomes, but pediatric residents spent more time and used more medical resources [6]. The role of the EP in providing emergency medical care to pediatric patients is evaluated in another prior article [7]. In this study, we investigated the effect of specialty training (emergency medicine vs pediatrics) on medical resource use, short-term outcomes, and dispositions stemming from the management of nontraumatic common pediatric illnesses in a general ED to find ways to improve the quality of monitoring and care.

Section snippets

Study design

This was a retrospective cohort review of visits to the ED by pediatric nontrauma patients. Our study protocol was reviewed by our institutional review board and deemed exempt from the requirement to obtain informed consent.

Study setting and population

The settings of this study were 2 university-affiliated teaching hospitals with EDs staffed by board-certified emergency medicine and pediatric attending physicians. At both sites, physicians provided 24-hour management of pediatric short-term nontrauma patients in a

Characteristics of study subjects

During the study period, the medical data for 27 487 patients were collected. There were 629 patients who were excluded based upon incompleteness of data. Finally, 26 858 patients were enrolled into this study. Of these patients, 13 966 were directly managed by EPs (group 1) and 12 892 were managed by pediatricians (group 2). Table 1 shows their demographics. There were insignificant between-group differences in mean age, sex, and triage category.

Costs and medical resources

Direct costs per visit were 9.6% higher in group

Overview

It was reported that physicians in the ED may manage pediatric patients differently because of their training [5], [10], [11]. Moreover, these differences could influence medical resource use [1] and indirectly influence ED LOS [1], [12], ED costs [1], [2], and even outcomes [2], [12], [13].

Our study demonstrated that pediatric patients in the ED treated by EPs (when compared to those treated by pediatric physicians) had comparable outcomes, but they also had longer ED LOS, used more resources

Conclusions

Compared to pediatricians, EPs spent more time, used more medical resources to treat pediatric patients in the ED, and admitted patients at a higher rate. Revisit rates within 72 hours were similar for patients in both groups. Emergency physicians and pediatricians managed critical patients similarly. More detailed study on the investigation of factors influencing the clinical care of pediatric emergency patients by physicians with different specialties should be implemented in the future.

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