Treatment of Children With Migraine in Emergency Departments: National Practice Variation Study

Richer, Lawrence; Laycock, Keri; Millar, Kelly; Fitzpatrick, Eleanor; Khangura, Simi; Bhatt, Maala; Guímont, Chantal; Neto, Gina; Noseworthy, Steve; Siemens, Ron; Gouin, Serge; Rowe, Brian H.

doi:10.1542/peds.2009-2337

Cited by 67 publications

(88 citation statements)

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“…This finding suggests the importance of local clinician practice styles as one important determinant of drug use. 14,[20][21][22] The majority of children residing in each HSA received most of their ambulatory care from within HSA providers. Therefore, the HSA prescription use measures likely reflect the care pattern of each area' s clinicians.…”

Section: Discussionmentioning

confidence: 99%

Small Geographic Area Variations in Prescription Drug Use

et al. 2014

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WHAT'S KNOWN ON THIS SUBJECT: Prescribing patterns in the US pediatric population are changing but not uniformly. A detailed examination of prescription variation is needed to better understand pharmacotherapy of children and to inform future exploration of the causes and consequences of diverse practices. WHAT THIS STUDY ADDS:We examine pediatric pharmacotherapy and quantify payer type differences and small geographic area variation. Substantial payer-type differences and regional variations were found, likely reflecting local practice cultures. Variation was greatest for medications used in situations of diagnostic and therapeutic uncertainty. abstract BACKGROUND: Despite the frequency of pediatric prescribing little is known about practice differences across small geographic regions and payer type (Medicaid and commercial). OBJECTIVE:The goal of this research was to quantify variation in prescription drug use among northern New England children. METHODS:Northern New England, all-payer administrative data (2007)(2008)(2009)(2010) permitted study of prescriptions for 949 821 children ages 0 to 17 years (1.75 million person-years [PYs]; 54% Medicaid, 46% commercial). Age-and gender adjusted overall and drug group-specific prescription use was quantified according to payer type (Medicaid or commercial) and within payer type across 69 hospital service areas (HSAs). We measured prescription fills per PY (rate) and annual, mean percentage of the population with any drug group-specific fills (prevalence). RESULTS:Overall mean annual prescriptions per PY were 3.4 (commercial) and 5.5 (Medicaid). Generally, these payer type differences were smaller than HSA-level variation within payer type. HSA-level rates of attention-deficit/hyperactivity disorder drug use (5th-95th percentile) varied twofold in Medicaid and more than twofold in commercially insured children; HSA-level antidepressant use varied more than twofold within each payer type. Antacid use varied threefold across HSAs and was highest in infants where commercial use paradoxically exceeded Medicaid. Prevalence of drug use varied as much as rates across HSAs.CONCLUSIONS: Prescription use was higher among Medicaid-insured than commercially insured children. Regional variation generally exceeded payer type differences, especially for drugs used in situations of diagnostic and therapeutic uncertainty. Efforts should advance best pediatric prescribing discussions and shared decision-making.

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Section: Discussionmentioning

confidence: 99%

Small Geographic Area Variations in Prescription Drug Use

et al. 2014

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“…Given the lack of conclusive national standards for the diagnosis and management of pediatric appendicitis in Canada, and the documented practice variation for other common pediatric emergency presentations, [36][37][38][39][40][41][42] the objective of this study was to characterize the variations in practice for the diagnosis and management of children with suspected appendicitis who were admitted to Canadian academic hospitals. The study aims were focused on 1) after-hours surgical intervention (primary aim, due to perceived implications for patient safety, and responsible resource utilization), 2) ED investigations including laboratory and imaging studies, and 3) ED interventions such as the administration of analgesia and antibiotics.…”

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confidence: 99%

Variation in the Diagnosis and Management of Appendicitis at Canadian Pediatric Hospitals

et al. 2015

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Objectives: The objective was to characterize the variations in practice in the diagnosis and management of children admitted to hospitals from Canadian pediatric emergency departments (EDs) with suspected appendicitis, specifically the timing of surgical intervention, ED investigations, and management strategies.Methods: Twelve sites participated in this retrospective health record review. Children aged 3 to 17 years admitted to the hospital with suspected appendicitis were eligible. Site-specific demographics, investigations, and interventions performed were recorded and compared. Factors associated with afterhours surgery were determined using generalized estimating equations logistic regression.Results: Of the 619 children meeting eligibility criteria, surgical intervention was performed in 547 (88%). After-hours surgery occurred in 76 of the 547 children, with significant variation across sites (13.9%, 95% confidence interval = 7.1% to 21.6%, p < 0.001). The overall perforation rate was 17.4% (95 of 547), and the negative appendectomy rate was 6.8% (37 of 547), varying across sites (p = 0.004 and p = 0.036, respectively). Use of inflammatory markers (p < 0.001), blood cultures (p < 0.001), ultrasound (p = 0.001), and computed tomography (p = 0.001) also varied by site. ED administration of narcotic analgesia and antibiotics varied across sites (p < 0.001 and p = 0.001, respectively), as did the type of surgical approach (p < 0.001). After-hours triage had a significant inverse association with after-hours surgery (p = 0.014).Conclusions: Across Canadian pediatric EDs, there exists significant variation in the diagnosis and management of children with suspected appendicitis. These results indicate that the best diagnostic and management strategies remain unclear and support the need for future prospective, multicenter studies to identify strategies associated with optimal patient outcomes.ACADEMIC EMERGENCY MEDICINE 2015;22:811-822 © 2015 by the Society for Academic Emergency Medicine A ppendicitis is the most common nontraumatic surgical emergency in children, 1,2 yet it continues to present diagnostic and management uncertainty.3 Current strategies for diagnosing appendicitis include the use of clinical scoring systems, 4-7 laboratory markers of infection and inflammation, [8][9][10] and

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“…We must move beyond research that simply mines databases or collects data to demonstrate variability. 1,10 Studies must also address whether these variations have negative outcomes and suggest solutions. If variation leads to poorer care and outcomes, then we should all be shouting from the rooftops and doing something about it.…”

Section: Niranjan Kissoon MDmentioning

confidence: 99%