1. Practice Variations Between Emergency Medicine and Pediatric Physicians in the Treatment of URI’s Nicole Colucci, DO, MAAP Resident, Emergency Medicine Resurrection Medical Center

2. Author and Co-investigators: Mary Frances Kordick, MBA, PhD, RN, CNAA,BC Mary Frances Kordick, MBA, PhD, RN, CNAA,BC Shu Chan, MD, MS, FACEP Shu Chan, MD, MS, FACEP We are indebted to: All Survey Respondents All Survey Respondents Study Team

3. INTRODUCTION/BACKGROUND High prevalence of URI’s seen in the emergency department High prevalence of URI’s seen in the emergency department  Most common cause of illness in children Overuse of unnecessary antimicrobials Overuse of unnecessary antimicrobials  Increasing antimicrobial resistance patterns Sources: Ipp M, Carson S, Petric M, Parkin PC. Rapid painless diagnosis of viral respiratory infection. Arch Dis Child 2002; 86(5):372-373. Jacobs RF. Judicious use of antibiotics for common pediatric respiratory infections. Pediatr Infect Dis J 2000; 19(9):938-943.

4. STUDY OBJECTIVE Examine practice variations between emergency medicine and pediatric physicians focusing on: Examine practice variations between emergency medicine and pediatric physicians focusing on:  The diagnosis and management of children with respiratory signs/ symptoms  Specifically, URI’s

5. CLINICAL RELEVANCE Reduce future resistance to antibiotics Reduce future resistance to antibiotics Monetary impact Monetary impact Identify future areas for improving education to physicians Identify future areas for improving education to physicians All previous studies evaluate pediatricians All previous studies evaluate pediatricians Sources: Jacobs RF. Judicious use of antibiotics for common pediatric respiratory infections. Pediatr Infect Dis J 2000; 19(9):938-943. Boccazzi A, Noviello S, Tonelli P, Coi P, Esposito S, Carnelli V. The decision-making process in antibacterial treatment of pediatric upper respiratory infections: A national prospective office-based observational study. Int J Infect Dis 2002; 6(2):103-107.

6. STUDY DESIGN Following acceptance by the IRB, a 22-item questionnaire focusing on the diagnosis and management of children(<15 years) with URI’s was e-mailed to all members listed in directories of SAEM and the AAP-subsection of pediatric emergency medicine Following acceptance by the IRB, a 22-item questionnaire focusing on the diagnosis and management of children(<15 years) with URI’s was e-mailed to all members listed in directories of SAEM and the AAP-subsection of pediatric emergency medicine A cover letter explaining the survey was sent with a hyperlink to the web-based survey site (Formsite.com) A cover letter explaining the survey was sent with a hyperlink to the web-based survey site (Formsite.com) Repeat e-mails were sent at weeks 3-4 after the initial mailing Repeat e-mails were sent at weeks 3-4 after the initial mailing

7. SURVEY QUESTIONS Do you utilize the diagnosis of upper respiratory infection (URI)? Do you utilize the diagnosis of upper respiratory infection (URI)? Is there an age in which URI is not an appropriate diagnosis? Is there an age in which URI is not an appropriate diagnosis?  If you answered “yes” to the previous question, choose your age criterion? Do you document pulse oximetry in children with respiratory symptoms? Do you document pulse oximetry in children with respiratory symptoms?

8. SURVEY QUESTIONS Is there an age criterion in which you always order a CXR to exclude evidence of pneumonia or other pathology? Is there an age criterion in which you always order a CXR to exclude evidence of pneumonia or other pathology? Is there a season in which you order a CXR more frequently? Is there a season in which you order a CXR more frequently? Do you prescribe or recommend medications when you diagnose URI? Do you prescribe or recommend medications when you diagnose URI? If you did not intend to provide a prescription for medication and the parent requests an antibiotic, what describes your most frequent action? If you did not intend to provide a prescription for medication and the parent requests an antibiotic, what describes your most frequent action?

9. DATA ANALYSIS Data downloaded from Formsite.com Data downloaded from Formsite.com Descriptive and chi-square statistics were completed using the Statistical Package for Social Sciences for Windows Version 11.5 Descriptive and chi-square statistics were completed using the Statistical Package for Social Sciences for Windows Version 11.5

10. RESULTS 3739 e-mails sent via two separate mailings 3739 e-mails sent via two separate mailings  Response Rate: 26.3%, N=728  Population:  EM physicians, 73.8% (n = 539)  Pediatric EM physicians, 24.0% (n = 175)  Remainder: non-physician practitioners and eliminated from the study

11. DEMOGRAPHICS Similar for both groups Similar for both groups  Gender: Male-70.3%  Board eligibility/certification: 81-84%  Primary site of practice: Urban/Academic Medical Centers Different between the groups of physicians Different between the groups of physicians  Pediatric population of patients seen  EM-25%  PEM-75-100%

12. RESULTS EM physicians are more likely to confine the diagnosis of URI to certain age groups (EM-49.9% vs PEM-29.1%; P=0.000) EM physicians are more likely to confine the diagnosis of URI to certain age groups (EM-49.9% vs PEM-29.1%; P=0.000)  >8 years old  Both groups agree that URI is an inappropriate diagnosis in children < 1 month old PEM are less likely to use antibiotics, decongestants or antihistamines for treatment in pediatric URI’s (next slide) PEM are less likely to use antibiotics, decongestants or antihistamines for treatment in pediatric URI’s (next slide)  Saline drops, antipyretics

13. EM (n = 539) PEM (n = 175) P value CXR36.9%8.0%0.000 Pulse oximetry 87.2%68.6%0.000 No antibiotics for URI’s 76.1%95.4%0.000 Use of decongestants or antihistamines for URI’s 90.2%77.1%0.000 Use of communication 92.6%98.3%0.131 RESULTS

14. DISCUSSION Pulse oximetry should be the fifth vital sign in children with respiratory signs/symptoms Pulse oximetry should be the fifth vital sign in children with respiratory signs/symptoms  Inexpensive  Diagnose mild to moderate hypoxia unsuspected by physical exam CXR should be ordered on children with respiratory signs/symptoms: CXR should be ordered on children with respiratory signs/symptoms:  0-3 months age, abnormal SaO2, occult fever work-up Sources: Mower WR, Sachs C, Nicklin EL, Baraff LJ. Pulse oximetry as a fifth pediatric vital sign. Pediatrics 1997; 99(5):681-686. Baraff LJ. Management of fever without source in infants and children. Ann Emerg Med 2000; 36(6):602-614.

15. DISCUSSION Multiple sources agree that the most common cause of URI’s is viral and has no indication for antibiotics Multiple sources agree that the most common cause of URI’s is viral and has no indication for antibiotics Studies on the efficacy of the use of antihistamines, cough suppressants and mucolytics in the treatment of URI’s do not change the course of the illness Studies on the efficacy of the use of antihistamines, cough suppressants and mucolytics in the treatment of URI’s do not change the course of the illness Sources: Morikawa M. Upper respiratory infection in acute pediatric care in internal conflict, Kosovo, 1999. J Trop Pediatr 2001; 47(6):379-382. Nambiar S, Schwartz RH, Sheridan MJ. Are pediatricians adhering to principles of judicious antibiotic use for upper respiratory tract infections? South Med J 2002; 95(10):1163-1167.

16. LIMITATIONS Survey response rate of 26.3% with two mailings Survey response rate of 26.3% with two mailings  Allow for a third mailing Limited population Limited population  Utilize more databases(ACEP, SAEM, AAP) Unable to clearly define specific prescribing patterns of antibiotics/ decongestants Unable to clearly define specific prescribing patterns of antibiotics/ decongestants  More precise questions No specific definition for URI No specific definition for URI

17. CONCLUSIONS Practice differences exist between emergency medicine and pediatric emergency medicine physicians Practice differences exist between emergency medicine and pediatric emergency medicine physicians Areas for additional education in both groups of physicians Areas for additional education in both groups of physicians  Indications for diagnostic tests  Lack of indication for antibiotics in the treatment of viral URI’s  Use of supportive care as treatment for URI’s  Allowing the physician to offer non- medication options to caregivers