First name
Morgan
Last name
Congdon

Title

Diagnostic Reasoning of Resident Physicians in the Age of Clinical Pathways.

Year of Publication

2022

Number of Pages

466-474

Date Published

08/2022

ISSN Number

1949-8357

Abstract

Background: Development of skills in diagnostic reasoning is paramount to the transition from novice to expert clinicians. Efforts to standardize approaches to diagnosis and treatment using clinical pathways are increasingly common. The effects of implementing pathways into systems of care during diagnostic education and practice among pediatric residents are not well described.

Objective: To characterize pediatric residents' perceptions of the tradeoffs between clinical pathway use and diagnostic reasoning.

Methods: We conducted a qualitative study from May to December 2019. Senior pediatric residents from a high-volume general pediatric inpatient service at an academic hospital participated in semi-structured interviews. We utilized a basic interpretive qualitative approach informed by a dual process diagnostic reasoning framework.

Results: Nine residents recruited via email were interviewed. Residents reported using pathways when admitting patients and during teaching rounds. All residents described using pathways primarily as management tools for patients with a predetermined diagnosis, rather than as aids in formulating a diagnosis. As such, pathways primed residents to circumvent crucial steps of deliberate diagnostic reasoning. However, residents relied on bedside assessment to identify when patients are "not quite fitting the mold" of the current pathway diagnosis, facilitating recalibration of the diagnostic process.

Conclusions: This study identifies important educational implications at the intersection of residents' cognitive diagnostic processes and use of clinical pathways. We highlight potential challenges clinical pathways pose for skill development in diagnostic reasoning by pediatric residents. We suggest opportunities for educators to leverage clinical pathways as a framework for development of these skills.

DOI

10.4300/JGME-D-21-01032.1

Alternate Title

J Grad Med Educ

PMID

35991115

Title

Evolution of pneumococcal serotype epidemiology in Botswana following introduction of 13-valent pneumococcal conjugate vaccine.

Year of Publication

2022

Number of Pages

e0262225

Date Published

2022

ISSN Number

1932-6203

Abstract

<p>Pneumococcal conjugate vaccines reduce the burden of invasive pneumococcal disease, but the sustained effect of these vaccines can be diminished by an increase in disease caused by non-vaccine serotypes. To describe pneumococcal serotype epidemiology in Botswana following introduction of 13-valent pneumococcal conjugate vaccine (PCV-13) in July 2012, we performed molecular serotyping of 268 pneumococcal strains isolated from 221 children between 2012 and 2017. The median (interquartile range) age of the children included in this analysis was 6 (3,12) months. Fifty-nine percent of the children had received at least one dose of PCV-13 and 35% were fully vaccinated with PCV-13. While colonization by vaccine serotypes steadily declined following PCV-13 introduction, 25% of strains isolated more than 3 years after vaccine introduction were PCV-13 serotypes. We also observed an increase in colonization by non-vaccine serotypes 21 and 23B, which have been associated with invasive pneumococcal disease and antibiotic resistance in other settings.</p>

DOI

10.1371/journal.pone.0262225

Alternate Title

PLoS One

PMID

34986196

Title

Impact of patient race/ethnicity on emergency department management of pediatric gastroenteritis in the setting of a clinical pathway.

Year of Publication

2021

Date Published

2021 Mar 20

ISSN Number

1553-2712

Abstract

<p><b>BACKGROUND: </b>Acute gastroenteritis (AGE) is a common pediatric diagnosis in emergency medicine, accounting for 1.7 million visits annually. Little is known about racial/ethnic differences in care in the setting of standardized care models.</p><p><b>METHODS: </b>We used quality improvement data for children 6 months to 18 years presenting to a large, urban pediatric emergency department (ED) treated via a clinical pathway for AGE/dehydration between 2011 and 2018. Race/ethnicity was evaluated as a single variable (non-Hispanic [NH]-White, NH-Black, Hispanic, and NH-other) related to ondansetron and intravenous fluid (IVF) administration, ED length of stay (LOS), hospital admission, and ED revisits using multivariable regression.</p><p><b>RESULTS: </b>Of 30,849 ED visits for AGE/dehydration, 18.0% were NH-White, 57.2% NH-Black, 12.5% Hispanic, and 12.3% NH-other. Multivariable mixed-effects generalized linear regression controlling for age, sex, triage acuity, payor, and language revealed that, compared to NH-White patients, NH-other patients were more likely to receive ondansetron (aOR [95% CI] 1.30 [1.17, 1.43]). NH-Black, Hispanic, and NH-other patients were significantly less likely to receive IVF (0.59 [0.53, 0.65]; 0.74 [0.64, 0.84]; 0.74 [0.65, 0.85]) or be admitted to the hospital (0.54 [0.45, 0.64]; 0.62 [0.49, 0.78]; 0.76 [0.61, 0.94]), respectively. NH-Black and Hispanic patients had shorter LOS (median 245 minutes for NH-White, 176 NH-Black, 199 Hispanic, and 203 NH-other patients) without significant differences in ED revisits.</p><p><b>CONCLUSIONS: </b>Despite the presence of a clinical pathway to guide care, NH-Black, Hispanic, and NH-other children presenting to the ED with AGE/dehydration were less likely to receive IVF or hospital admission and had shorter LOS compared to NH-White counterparts. There was no difference in patient revisits which suggests discretionary overtreatment of NH-White patients, even with clinical guidelines in place. Further research is needed to understand the drivers of differences in care to develop interventions promoting equity in pediatric emergency care.</p>

DOI

10.1111/acem.14255

Alternate Title

Acad Emerg Med

PMID

33745207

Title

Effect of Haemophilus influenzae type b and 13-valent pneumococcal conjugate vaccines on childhood pneumonia hospitalizations and deaths in Botswana.

Year of Publication

2020

Date Published

2020 Jul 08

ISSN Number

1537-6591

Abstract

<p><strong>BACKGROUND: </strong>Globally, pneumonia is the leading cause of death among children. Few data exist regarding the effect of Haemophilus influenzae type b (Hib) vaccine and 13-valent pneumococcal conjugate vaccine (PCV-13) on the burden of childhood pneumonia in African settings.</p>

<p><strong>METHODS: </strong>We collected data on children 1 to 59 months of age at three hospitals in Botswana. Hib vaccine and PCV-13 were introduced in Botswana in November 2010 and July 2012, respectively. We compared pneumonia hospitalizations and deaths pre-vaccine (January 2009 to October 2010) to post-vaccine (January 2013 to December 2017) using seasonally-adjusted interrupted time-series analyses.</p>

<p><strong>FINDINGS: </strong>We identified 6943 pneumonia hospitalizations and 201 pneumonia deaths. In the pre-vaccine period, pneumonia hospitalizations and deaths increased by 24% (rate: 1.24; 95% CI: 0.94, 1.64) and 59% (rate: 1.59; 95% CI: 0.87, 2.90) per year, respectively. Vaccine introduction was associated with a 48% (95% CI: 29%, 62%) decrease in the number of pneumonia hospitalizations and a 50% (95% CI: 1%, 75%) decrease in the number of pneumonia deaths between the end of the pre-vaccine period (October 2010) and the beginning of the post-vaccine period (January 2013). During the post-vaccine period, pneumonia hospitalizations and deaths declined by 6% (rate 0.94; 95% CI: 0.89, 0.99) and 22% (rate: 0.78; 95% CI: 0.67, 0.92) per year, respectively.</p>

<p><strong>INTERPRETATION: </strong>Pneumonia hospitalizations and deaths among children declined sharply following introduction of Hib vaccine and PCV-13 in Botswana. This effect was sustained for more than five years after vaccine introduction, supporting the long-term effectiveness of these vaccines in preventing childhood pneumonia in Botswana.</p>

DOI

10.1093/cid/ciaa919

Alternate Title

Clin. Infect. Dis.

PMID

32634831

Title

Pediatric provider perspectives and practices regarding health policy discussions with families: a mixed methods study.

Year of Publication

2020

Number of Pages

343

Date Published

2020 Jul 13

ISSN Number

1471-2431

Abstract

<p><strong>BACKGROUND: </strong>Advocacy regarding child health policy is a core tenet of pediatrics. Previous research has demonstrated that most pediatric providers believe collective advocacy and political involvement are essential aspects of their profession, but less is known about how pediatric providers engage with families about policy issues that impact child health. The objectives of this study were to examine providers' perceptions and practices with regards to discussing health policy issues with families and to identify provider characteristics associated with having these discussions.</p>

<p><strong>METHODS: </strong>In this cross-sectional mixed methods study, pediatric resident physicians, attending physcians, and nurse practitioners at primary care clinics within a large academic health system were surveyed to assess (1) perceived importance of, (2) frequency of, and (3) barriers to and facilitators of health policy discussions with families. Multivariable ordinal regression was used to determine provider characteristics (including demographics, practice location, and extent of civic engagement) associated with frequency of these discussions. A subset of providers participated in subsequent focus groups designed to help interpret quantitative findings.</p>

<p><strong>RESULTS: </strong>The overall survey response rate was 155/394 (39%). The majority of respondents (76%) felt pediatricians should talk to families about health policy issues affecting children, but most providers (69%) reported never or rarely having these discussions. Factors associated with discussing policy issues included being an attending physician/nurse practitioner (OR 8.22, 95% CI 2.04-33.1) and urban practice setting (OR 3.85, 95% CI 1.03-14.3). Barriers included feeling uninformed about relevant issues and time constraints. In provider focus groups, four key themes emerged: (1) providers felt discussing policy issues would help inform and empower families; (2) providers frequently discussed social service programs, but rarely discussed policies governing these programs; (3) time constraints and concerns about partisan bias were a barrier to conversations; and (4) use of support staff and handouts with information about policy changes could help facilitate more frequent conversations.</p>

<p><strong>CONCLUSIONS: </strong>Pediatric providers felt it was important to talk to families about child health policy issues, but few providers reported having such conversations in practice. Primary care practices should consider incorporating workflow changes that promote family engagement in relevant health policy discussions.</p>

DOI

10.1186/s12887-020-02238-y

Alternate Title

BMC Pediatr

PMID

32660527

Title

Continuous Intragastric Dextrose: A Therapeutic Option for Refractory Hypoglycemia in Congenital Hyperinsulinism.

Year of Publication

2019

Number of Pages

62-68

Date Published

2019

ISSN Number

1663-2826

Abstract

<p>Feeding problems are frequent in infants with congenital hyperinsulinism (HI) and may be exacerbated by continuous enteral nutrition (EN) used to maintain euglycemia. Our center's HI team uses dextrose solution given continuously via gastric tube (intrasgastric dextrose, IGD) for infants not fully responsive to conventional medical therapy or pancreatectomy. Here, we describe our practice as well as growth, feeding, and adverse events in infants with HI exposed to IGD.</p>

<p><strong>METHODS: </strong>This was a retrospective cohort of infants with HI treated with IGD from 2009-2017. Primary outcomes were weight-for-length and body mass index Z-scores (WFL-Z and BMI-Z) in the year following IGD initiation. Secondary outcomes included EN use and adverse events. We used multivariable regression to assess covariates of interest.</p>

<p><strong>RESULTS: </strong>We studied 32 subjects (13 female) with a median age at IGD initiation of 73 days (range 17-367); median follow-up was 11.2 months (range 5.0-14.2). WFL-Z did not change significantly over time (p &gt; 0.05). EN use decreased significantly over time, i.e., at 0 months: 72% (95% CI 53-85) vs. at 12 months 39% (95% CI 22-59). No potential adverse events led to discontinuation of IGD.</p>

<p><strong>CONCLUSIONS: </strong>Over a median follow-up of nearly 1 year, IGD was well-tolerated, with no change in WFL-Z or BMI-Z from baseline.</p>

DOI

10.1159/000491105

Alternate Title

Horm Res Paediatr

PMID

30086540

WATCH THIS PAGE

Subscription is not available for this page.