Sex-specific differences in children attending the emergency department: prospective observational study

Sex differences in children operated with pyeloplasty for pelvoureteric junction obstruction

PURPOSE

Pelvoureteric junction obstruction (UPJO) is a common cause of hydronephrosis in children but no previous studies have evaluated differences between boys and girls operated with pyeloplasty. This study aimed to evaluate potential differences between sexes in children operated with pyeloplasty for PUJO in terms of presentation, surgery, and long-term results.

METHODS

Data was retrospectively collected from all children operated on with pyeloplasty between January 2002 and December 2020. Data contained several variables covering presentation, surgery, and long-term results.

RESULTS

In total, 194 patients were included of which 126 (64.9%) were boys. There were no significant differences in prenatal findings, pelvic dilation on ultrasound, function of the affected kidney, surgical method, obstruction type, resolution of hydronephrosis, or improvement of function. Boys presented with pain more often than girls (47.4 vs 25.0%, p < 0.01) while girls were more prone to infections preoperatively (17.2 vs 7.0%, p = 0.04). All nine patients requiring reoperation were boys (p = 0.03).

CONCLUSION

Girls with UPJO seem to experience infections as presenting symptoms more often than boys, while boys significantly more often present with pain. There is also a higher percentage of boys needing reoperation.

Factors associated with frequent users in hospital paediatric emergency departments: A single centre study in Spain

BACKGROUND

Over the last decade, the demand for hospital paediatric emergency departments (PEDs) has been on the rise. Studies have been carried out in adults, but in paediatrics, and in Spain, they are few and far between. In order to develop interventions to alleviate this problem, it is necessary to understand the factors that predispose people to use these services.

OBJECTIVE

The main objective of this study was to identify the factors associated with frequent users of PEDs in Spain.

METHODS

A descriptive, cross-sectional study conducted between September 2021 and December 2022 in the PED of a referral hospital in Spain.

RESULTS

There were 530 participants, 12.07% of whom were frequent users. There was an indirect association between frequent use and having a secondary level of education (OR = 0.282, p = 0.002). The factors which were directly associated included: perceived urgency (OR = 10.209, p = 0.002) and the perception that PEDs provide better care than primary care (PC) (OR = 2.664, p = 0.044).

CONCLUSIONS

The percentage of frequent users is comparable with international levels. As a strategy to reduce the frequency of visits, health interventions are needed to ensure that parents know how to correctly interpret their children's symptoms and are well informed about the recommended flow of care.

Factors Associated With Inpatient Subspecialty Consultation Patterns Among Pediatric Hospitalists

IMPORTANCE

Subspecialty consultation is a frequent, consequential practice in the pediatric inpatient setting. Little is known about factors affecting consultation practices.

OBJECTIVES

To identify patient, physician, admission, and systems characteristics that are independently associated with subspecialty consultation among pediatric hospitalists at the patient-day level and to describe variation in consultation utilization among pediatric hospitalist physicians.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study of hospitalized children used electronic health record data from October 1, 2015, through December 31, 2020, combined with a cross-sectional physician survey completed between March 3 and April 11, 2021. The study was conducted at a freestanding quaternary children's hospital. Physician survey participants were active pediatric hospitalists. The patient cohort included children hospitalized with 1 of 15 common conditions, excluding patients with complex chronic conditions, intensive care unit stay, or 30-day readmission for the same condition. Data were analyzed from June 2021 to January 2023.

EXPOSURES

Patient (sex, age, race and ethnicity), admission (condition, insurance, year), physician (experience, anxiety due to uncertainty, gender), and systems (hospitalization day, day of week, inpatient team, and prior consultation) characteristics.

MAIN OUTCOMES AND MEASURES

The primary outcome was receipt of inpatient consultation on each patient-day. Risk-adjusted consultation rates, expressed as number of patient-days consulting per 100, were compared between physicians.

RESULTS

We evaluated 15 922 patient-days attributed to 92 surveyed physicians (68 [74%] women; 74 [80%] with ≥3 years' attending experience) caring for 7283 unique patients (3955 [54%] male patients; 3450 [47%] non-Hispanic Black and 2174 [30%] non-Hispanic White patients; median [IQR] age, 2.5 ([0.9-6.5] years). Odds of consultation were higher among patients with private insurance compared with those with Medicaid (adjusted odds ratio [aOR], 1.19 [95% CI, 1.01-1.42]; P = .04) and physicians with 0 to 2 years of experience vs those with 3 to 10 years of experience (aOR, 1.42 [95% CI, 1.08-1.88]; P = .01). Hospitalist anxiety due to uncertainty was not associated with consultation. Among patient-days with at least 1 consultation, non-Hispanic White race and ethnicity was associated with higher odds of multiple consultations vs non-Hispanic Black race and ethnicity (aOR, 2.23 [95% CI, 1.20-4.13]; P = .01). Risk-adjusted physician consultation rates were 2.1 times higher in the top quartile of consultation use (mean [SD], 9.8 [2.0] patient-days consulting per 100) compared with the bottom quartile (mean [SD], 4.7 [0.8] patient-days consulting per 100; P < .001).

CONCLUSIONS AND RELEVANCE

In this cohort study, consultation use varied widely and was associated with patient, physician, and systems factors. These findings offer specific targets for improving value and equity in pediatric inpatient consultation.

Factors associated with the inappropriate use of the pediatric emergency department. A systematic review

BACKGROUND

Pediatric emergency department (PED) admissions have risen in recent years, a trend not justified by the severity of the pathologies presented. The aim of this study is to analyse factors related to the inappropriate use of pediatric emergency departments.

METHODS

This is a systematic review reported in accordance with the PRISMA statement. We searched the PubMed, Web of Science and Science Direct databases, using keywords extracted from MeSH, and conducted a reverse search using Google Scholar and Open Grey, for the period January 2017 to August 2022. The quality of the papers was assessed using STROBE, CASPe, AMSTAR-2, GRADE, Levels Of Evidence and Grades Of Recommendation.

RESULTS

A total of 20 studies were selected. Factors related to inappropriate use included the younger age of children, black caregivers, lower socioeconomic status, lower parental educational attainment, perceived urgent demand for care, parental emotions in response to their children's health problems, psychological distress, the ineffective exercise of the parental role, the advantages of the PED and the nature of health insurance.

CONCLUSIONS AND IMPLICATIONS

The results illustrate the heterogeneous nature of the phenomenon under investigation. Gaining an understanding of the factors related to the inappropriate demand of PEDs, from the perspective of health professionals, can help in developing interventions to reduce unnecessary consultations and relieve pressure on these healthcare services.

Sex differences in febrile children with respiratory symptoms attending European emergency departments: An observational multicenter study

Objective

To assess sex differences in presentation and management of febrile children with respiratory symptoms attending European Emergency Departments.

Design and setting

An observational study in twelve Emergency Departments in eight European countries.

Patients

Previously healthy children aged 0–<18 years with fever (≥ 38°C) at the Emergency Department or in the consecutive three days before Emergency Department visit and respiratory symptoms were included.

Main outcome measures

The main outcomes were patient characteristics and management defined as diagnostic tests, treatment and admission. Descriptive statistics were used for patient characteristics and management stratified by sex. Multivariable logistic regression analyses were performed for the association between sex and management with adjustment for age, disease severity and Emergency Department. Additionally, subgroup analyses were performed in children with upper and lower respiratory tract infections and in children below five years.

Results

We included 19,781 febrile children with respiratory symptoms. The majority were boys (54%), aged 1–5 years (58%) and triaged as low urgent (67%). Girls presented less frequently with tachypnea (15% vs 16%, p = 0.002) and increased work of breathing (8% vs 12%, p<0.001) compared with boys. Girls received less inhalation medication than boys (aOR 0.82, 95% CI 0.74–0.90), but received antibiotic treatment more frequently than boys (aOR 1.09, 95% CI 1.02–1.15), which is associated with a higher prevalence of urinary tract infections. Amongst children with a lower respiratory tract infection and children below five years girls received less inhalation medication than boys (aOR 0.77, 95% CI 0.66–0.89; aOR 0.80, 95% CI 0.72–0.90).

Conclusions

Sex differences concerning presentation and management are present in previously healthy febrile children with respiratory symptoms presenting to the Emergency Department. Future research should focus on whether these differences are related to clinicians’ attitudes, differences in clinical symptoms at the time of presentation and disease severity.

Improving triage for children with comorbidity using the ED-PEWS: an observational study

OBJECTIVE

To assess the value of the Emergency Department-Pediatric Early Warning Score (ED-PEWS) for triage of children with comorbidity.

DESIGN

Secondary analysis of a prospective cohort.

SETTING AND PATIENTS

53 829 consecutive ED visits of children <16 years in three European hospitals (Netherlands, UK and Austria) participating in the TrIAGE (Triage Improvements Across General Emergency departments) project in different periods (2012-2015).

INTERVENTION

ED-PEWS, a score consisting of age and six physiological parameters.

MAIN OUTCOME MEASURE

A three-category reference standard as proxy for true patient urgency. We assessed discrimination and calibration of the ED-PEWS for children with comorbidity (complex and non-complex) and without comorbidity. In addition, we evaluated the value of adding the ED-PEWS to the routinely used Manchester Triage System (MTS).

RESULTS

5053 (9%) children had underlying non-complex morbidity and 5537 (10%) had complex comorbidity. The c-statistic for identification of high-urgency patients was 0.86 (95% prediction interval 0.84-0.88) for children without comorbidity, 0.87 (0.82-0.92) for non-complex and 0.86 (0.84-0.88) for complex comorbidity. For high and intermediate urgency, the c-statistic was 0.63 (0.62-0.63), 0.63 (0.61-0.65) and 0.63 (0.55-0.73) respectively. Sensitivity was slightly higher for children with comorbidity (0.73-0.75 vs 0.70) at the cost of a lower specificity (0.86-0.87 vs 0.92). Calibration was largely similar. Adding the ED-PEWS to the MTS for children with comorbidity improved performance, except in the setting with few high-urgency patients.

CONCLUSIONS

The ED-PEWS has a similar performance in children with and without comorbidity. Adding the ED-PEWS to the MTS for children with comorbidity improves triage, except in the setting with few high-urgency patients.

Shortness of breath in children at the emergency department: Variability in management in Europe

OBJECTIVE

Our aim was to describe variability in resource use and hospitalization in children presenting with shortness of breath to different European Emergency Departments (EDs) and to explore possible explanations for variability.

DESIGN

The TrIAGE project, a prospective observational study based on electronic health record data.

PATIENTS AND SETTING

Consecutive paediatric emergency department visits for shortness of breath in five European hospitals in four countries (Austria, Netherlands, Portugal, United Kingdom) during a study period of 9-36 months (2012-2014).

MAIN OUTCOME MEASURES

We assessed diversity between EDs regarding resource use (diagnostic tests, therapy) and hospital admission using multivariable logistic regression analyses adjusting for potential confounding variables.

RESULTS

In total, 13,552 children were included. Of those, 7,379 were categorized as immediate/very urgent, ranging from 13-80% in the participating hospitals. Laboratory tests and X-rays were performed in 8-33% of the cases and 21-61% was treated with inhalation medication. Admission rates varied between 8-47% and PICU admission rates varied between 0.1-9%. Patient characteristics and markers of disease severity (age, sex, comorbidity, urgency, vital signs) could explain part of the observed variability in resource use and hospitalization. However, after adjusting for these characteristics, we still observed substantial variability between settings.

CONCLUSION

European EDs differ substantially regarding the resource use and hospitalization in children with shortness of breath, even when adjusting for patient characteristics. Possible explanations for this variability might be unmeasured patient characteristics such as underlying disease, differences in guideline use and adherence or different local practice patterns.