Large Variation in Clinical Practice amongst Pediatricians in Treating Children with Recurrent Abdominal Pain

Abstract

Purpose To evaluate intra- and inter-observer variability and guideline adherence amongst pediatricians in treating children aged between 4 and 18 years referred with recurrent abdominal pain (RAP) without red flags. Methods The first part of the study is a retrospective single-center cohort study. The diagnostic work-ups of eight pediatricians were compared to the national guidelines. Intra- and inter-observer variability were examined by Cramer's V test. Intra-observer variability was defined as the amount of variation within a pediatrician and inter-observer variability as the amount of variation between pediatricians in the application of diagnostic work-up in children with RAP. Prospectively, the same pediatricians were requested to provide a report on their management strategy with a fictitious case to prove similarities in retrospective diagnostic work-up. Results A total of 10 patients per pediatrician were analyzed. Retrospectively, a (very) weak association between pediatricians' diagnostic work-ups was found (0.22), which implies high inter-observer variability. The association between intra-observer diagnostic was moderate (range, 0.35–0.46). The Cramer's V of 0.60 in diagnostic work-up between pediatricians in the fictitious case implied the presence of a moderately strong association and lower inter-observer variability than in the retrospective study. Adherence to the guideline was 66.8%. Conclusion We found a high intra- and inter-observer variability and moderate guideline adherence in daily clinical practice amongst pediatricians in treating children with RAP in a teaching hospital.

Guideline adherence and clinical relevance of laboratory investigations during follow‐up in paediatric coeliac disease: A Dutch single‐centre cohort study

“…Our study shows that non‐adherence to guidelines during the follow‐up of paediatric CD led to the execution of unnecessary tests with only 4.4% clinically relevant deviations in laboratory tests. Non‐adherence to guidelines amongst paediatricians, despite the presence of well‐defined evidence‐based guidelines, has been shown by previous research in CD, where for instance biopsy guidelines are not strictly followed by paediatric gastroenterologists and in several other paediatric conditions 20‐23 . Previous studies provided several reasons why clinicians would deviate from available guidelines of which some are difficult to address: availability of too many guidelines, decreased sense of autonomy, guidelines are not specific enough, oversimplification of medicine, uncertainty regarding the evidence on which guidelines are based and the way clinicians have treated patients throughout their career without problems 24‐26 .…”

“…Furthermore, variation in clinical practice can also be caused by various cultural, psychological and local factors which influences the behaviour of clinicians which cannot be incorporated into guidelines. It is known that publication of guidelines do not guarantee the clinical implementation and adherence by clinicians.20,22,23 Although nonadherence to guidelines may consequently lead to the execution of unnecessary tests leading to false-positive or false-negative results, unnecessary anxiety in children and their parents, and the generation of financial costs, the reverse is also true in case of strict adherence. Whether or not strict guideline adherence during follow-up of paediatric CD leads to a reduction in the execution of unnecessary…”