Published online March 1, 2006
PEDIATRICS Vol. 117 No. 3 March 2006, pp. 787-795 (doi:10.1542/10.1542/peds.2005-0947)

This Article Full Text Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Web of Science (3) Citing Articles via Google Scholar Google Scholar Articles by Bergman, D. A. Articles by Wasserman, R. C. Search for Related Content PubMed PubMed Citation Articles by Bergman, D. A. Articles by Wasserman, R. C. Related Collections Office Practice Social Bookmarking                         What's this?

Does Clinical Presentation Explain Practice Variability in the Treatment of Febrile Infants?

David A. Bergman, MD^a, Michelle L. Mayer, PhD, MPH, RN^b, Robert H. Pantell, MD^c, Stacia A. Finch, MA^d and Richard C. Wasserman, MD, MPH^e

^a Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
^b Cecil B. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
^c Department of Pediatrics, University of California, San Francisco, San Francisco, California
^d American Academy of Pediatrics, Elk Grove Village, Illinois
^e Department of Pediatrics, University of Vermont, Burlington, Vermont

BACKGROUND. Previous studies documented considerable variability in the treatment of febrile infants, despite the existence of practice guidelines for this condition. None of those studies documented the extent to which this variability is accounted for by differences in clinical severity.

OBJECTIVE. To quantify the individual effects of the patient's clinical presentation, demographic, provider, and practice characteristics, and regional variables on practice variability in the evaluation and treatment of febrile infants.

METHODS. With data collected through the Pediatric Research in Office Settings network, we analyzed data on the treatment of 2712 febrile infants examined by 484 pediatricians located in 194 practices. We analyzed hospitalization, lumbar puncture, urinalysis and/or urine culture, blood work, and initial antibiotic administration. We obtained a summary score for evaluation and treatment intensity (ranging from no tests or treatments to comprehensive testing, hospitalization, and antibiotic therapy) by performing principal-components analysis with these 5 variables. This summary score was regressed with respect to patients' clinical presentation, demographic and practice/practitioner features, and geographic region. Provider fixed effects were also included in the model.

RESULTS. Although the overall model explained 46.5% of the variance, the clinical characteristics of the patient alone explained 29.7% of the overall variance. Practice site fixed effects explained nearly 15% of the overall variance. Provider and practitioner characteristics and geographic region had minimal explanatory power.

CONCLUSIONS. Our results show that measures of the patient's clinical presentation account for nearly one third of the variability that our model explains. This suggests that differences in clinical presentation and severity of illness underlie much of the observed practice variability among pediatricians evaluating and treating febrile infants. These findings demonstrate that the management of this common and potentially serious condition depends more on the clinical presentation of the patient than on the characteristics of the provider/practice and the residential region.

---

Key Words: practice variability • febrile infants • practice guidelines

Abbreviations: PROS—Pediatric Research in Office Settings • AAP—American Academy of Pediatrics • HMO—health maintenance organization

---

Accepted Aug 3, 2005.

CiteULike    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

This article has been cited by other articles:

				J. M. Stancil, T. R. Peters, L. B. Givner, and K. A. Poehling Potential Impact of Accelerating the Primary Dose of Pneumococcal Conjugate Vaccine in Infants Arch Pediatr Adolesc Med, May 1, 2009; 163(5): 422 - 425. [Abstract] [Full Text] [PDF]

				L. M. Luginbuhl, T. B. Newman, R. H. Pantell, S. A. Finch, and R. C. Wasserman Office-Based Treatment and Outcomes for Febrile Infants With Clinically Diagnosed Bronchiolitis Pediatrics, November 1, 2008; 122(5): 947 - 954. [Abstract] [Full Text] [PDF]

				M. Chung, G. Raman, T. Trikalinos, J. Lau, and S. Ip Interventions in Primary Care to Promote Breastfeeding: An Evidence Review for the U.S. Preventive Services Task Force Ann Intern Med, October 21, 2008; 149(8): 565 - 582. [Abstract] [Full Text] [PDF]

				M. S Kramer, L. Matush, I. Vanilovich, R. Platt, N. Bogdanovich, Z. Sevkovskaya, I. Dzikovich, G. Shishko, B. Mazer, and the Promotion of Breastfeeding Intervention Trial Effect of prolonged and exclusive breast feeding on risk of allergy and asthma: cluster randomised trial BMJ, October 20, 2007; 335(7624): 815 - 815. [Abstract] [Full Text] [PDF]

				from the AAP Division of Primary Care Research Study looks at factors that influence treatment of febrile infants AAP News, May 1, 2006; 27(5): 9 - 9. [Full Text]