What matters when managing childhood fever in the emergency department? A discrete-choice experiment comparing the preferences of parents and healthcare professionals in the UK

Abstract

Background Fever among children is a leading cause of emergency department (ED) attendance and a diagnostic conundrum; yet robust quantitative evidence regarding the preferences of parents and healthcare providers (HCPs) for managing fever is scarce. Objective To determine parental and HCP preferences for the management of paediatric febrile illness in the ED. Setting Ten children's centres and a children's ED in England from June 2018 to January 2019. Participants 98 parents of children aged 0-11 years, and 99 HCPs took part. Methods Nine focus-groups and coin-ranking exercises were conducted with parents, and a discrete-choice experiment (DCE) was conducted with both parents and HCPs, which asked respondents to choose their preferred option of several hypothetical management scenarios for paediatric febrile illness, with differing levels of visit time, out-of-pocket costs, antibiotic prescribing, HCP grade and pain/discomfort from investigations. Results The mean focus-group size was 4.4 participants (range 3-7), with a mean duration of 27.4 min (range 18-46 min). Response rates to the DCE among parents and HCPs were 94.2% and 98.2%, respectively. Avoiding pain from diagnostics, receiving a faster diagnosis and minimising wait times were major concerns for both parents and HCPs, with parents willing-to-pay £16.89 for every 1 hour reduction in waiting times. Both groups preferred treatment by consultants and nurse practitioners to treatment by doctors in postgraduate training. Parents were willing to trade-off considerable increases in waiting times (24.1 min) to be seen by consultants and to avoid additional pain from diagnostics (45.6 min). Reducing antibiotic prescribing was important to HCPs but not parents. Conclusions Both parents and HCPs care strongly about reducing visit time, avoiding pain from invasive investigations and receiving diagnostic insights faster when managing paediatric febrile illness. As such, overdue advances in diagnostic capabilities should improve child and carer experience and HCP satisfaction considerably in managing paediatric febrile illness.

A NICE combination for predicting hospitalisation at the Emergency Department: a European multicentre observational study of febrile children

“…Fever in infants and children is one of the most common reasons to present to the ED, accounting for up to 20-30% of ED visits. [1] …”

“…Most children with fever will suffer from self-limiting viral illnesses, however, the clinical presentations of self-limiting viral and life-threatening bacterial infections may be identical, making diagnosis based on clinical judgement alone a difficult task. [1] If life-threatening infections are not recognised in time, this may have disastrous consequences, such as mortality, long-term morbidity or ICU admission, highlighting the daily challenge of caring for this broad group of children. As a result, an elaborate approach is often used, characterised by multiple investigations, evaluation of treatment effect at the ED or hospital admission for observation [ 1 , 2 ].…”

“… [1] If life-threatening infections are not recognised in time, this may have disastrous consequences, such as mortality, long-term morbidity or ICU admission, highlighting the daily challenge of caring for this broad group of children. As a result, an elaborate approach is often used, characterised by multiple investigations, evaluation of treatment effect at the ED or hospital admission for observation [ 1 , 2 ]. Unfortunately, such interventions are invasive, costly and are likely to prolong a child's visit to the ED, contributing to extended ED waiting times and ED crowding [1] .…”

“…As a result, an elaborate approach is often used, characterised by multiple investigations, evaluation of treatment effect at the ED or hospital admission for observation [ 1 , 2 ]. Unfortunately, such interventions are invasive, costly and are likely to prolong a child's visit to the ED, contributing to extended ED waiting times and ED crowding [1] .…”

“…Regarding patient and healthcare staff satisfaction, ED waiting times are one of the most important factors influencing parental satisfaction [1] and crowding is one of the factors contributing to health care staff “compassion fatigue”, a reduced capacity and interest in being empathetic for suffering individuals, that has a further negative impact on quality of care [5] .…”