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van der Velden FJS, Lim E, Smith H, Walsh R, Emonts M. Quantifying the costs of hospital admission for families of children with a febrile illness in the North East of England. BMJ Paediatr Open 2024; 8:e002489. [PMID: 38844385 PMCID: PMC11163670 DOI: 10.1136/bmjpo-2023-002489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 05/09/2024] [Indexed: 06/12/2024] Open
Abstract
OBJECTIVE To assess the financial non-medical out-of-pocket costs of hospital admissions for children with a febrile illness. DESIGN Single-centre survey-based study conducted between March and November 2022. SETTING Tertiary level children's hospital in the North East of England. PARTICIPANTS Families of patients with febrile illness attending the paediatric emergency department MAIN OUTCOME MEASURES: Non-medical out-of-pocket costs for the admission were estimated by participants including: transport, food and drinks, child care, miscellaneous costs and loss of earnings. RESULTS 83 families completed the survey. 79 families (95.2%) reported non-medical out-of-pocket costs and 19 (22.9%) reported financial hardship following their child's admission.Total costs per day of admission were median £56.25 (IQR £32.10-157.25). The majority of families reported incurring transport (N=75) and food and drinks (N=71) costs. CONCLUSIONS A child's hospital admission for fever can incur significant financial costs for their family. One in five participating families reported financial hardship following their child's admission. Self-employed and single parents were disadvantaged by unplanned hospital admissions and at an increased risk of financial hardship. Local hospital policies should be improved to support families in the current financial climate.
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Affiliation(s)
- Fabian Johannes Stanislaus van der Velden
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Paediatric Immunology, Infectious Diseases and Allergy, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Great North Children's Hospital, Newcastle Upon Tyne, UK
| | - Emma Lim
- General Paediatrics & Paediatric Immunology, Infectious Diseases & Allergy, Great North Children's Hospital, Newcastle Upon Tyne, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Holly Smith
- General Paediatrics, Great North Children's Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Rebecca Walsh
- General Paediatrics, Great North Children's Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Marieke Emonts
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Paediatric Immunology, Infectious Diseases and Allergy, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Great North Children's Hospital, Newcastle Upon Tyne, UK
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van Schie R, Coolen E, van Tuijl A, van der Velden J, Thoonen B, Scherpbier-de Haan N. Intraprofessional boundary crossing in acute paediatric care: A rich journey for general practice and paediatric residents. MEDICAL EDUCATION 2024. [PMID: 38741165 DOI: 10.1111/medu.15423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 03/26/2024] [Accepted: 04/16/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Achieving optimal collaboration between general practitioners and hospital-based critical care doctors is vital yet challenging, necessitating targeted collaborative training during residency. Despite apparent benefits, implementing intraprofessional learning faces constraints. Understanding its occurrence is crucial for engaging and educating residents. Considering boundaries' learning potential, we developed and evaluated an educational programme for general practitioner (GP) and paediatric (P) residents in paediatric emergency care based on Akkerman's Boundary Crossing Theory. The study investigated how intraprofessional learning mechanisms occurred and what learning conditions facilitated or impeded learning of GP and P residents, aiming to optimise educational programme design for intraprofessional collaboration. METHODS We developed an educational programme with three activities: joint medical assessments of paediatric patients in each other's context, mutually mini-Clinical Evaluation Exercises (mini-CEXs) about intraprofessional collaboration skills and educational meetings about collaborative care. We performed a qualitative study with a constructivist approach to explore experiences of the programme. We conducted focus group interviews and analysed mini-CEXs, utilising Boundary Crossing theory for template analysis. RESULTS Ten GP and eight P residents participated in our study. Learning mechanisms of identification and coordination dominated the joint medical assessments. Mini-CEXs stimulated reflection. Educational meetings with supervisors about intraprofessional barriers initiated transformation. Facilitated learning conditions were bidirectional crossing, enthusiastic supervisors, residents being familiar with each other, clear mini-CEX design and authentic paediatric cases. Unclear mutual expectations during joint medical assessments impeded learning of residents. CONCLUSIONS Working in each other's context triggers learning mechanisms of identification, coordination and reflection, forming the basis for intraprofessional learning in paediatric emergency care for GP and P residents. For development of new collaboration practices, supervisors are necessary to translate reflection into transformation. Mutual responsibilities and expectations should be made more explicit to create a safer intraprofessional learning environment. Our findings extend to other medical training contexts, leveraging boundaries for learning.
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Affiliation(s)
- Rosalin van Schie
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ester Coolen
- Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Anne van Tuijl
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Bart Thoonen
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nynke Scherpbier-de Haan
- Department of General Practice and Elderly Care, University Medical Centre Groningen, Groningen, Netherlands
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Dillen H, Wouters J, Snijders D, Wynants L, Verbakel JY. Factors associated with inappropriateness of antibiotic prescriptions for acutely ill children presenting to ambulatory care in high-income countries: a systematic review and meta-analysis. J Antimicrob Chemother 2024; 79:498-511. [PMID: 38113395 PMCID: PMC10904728 DOI: 10.1093/jac/dkad383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Acutely ill children are at risk of unwarranted antibiotic prescribing. Data on the appropriateness of antibiotic prescriptions provide insights into potential tailored interventions to promote antibiotic stewardship. OBJECTIVES To examine factors associated with the inappropriateness of antibiotic prescriptions for acutely ill children presenting to ambulatory care in high-income countries. METHODS On 8 September 2022, we systematically searched articles published since 2002 in MEDLINE, Embase, CENTRAL, Web of Science, and grey literature databases. We included studies with acutely ill children presenting to ambulatory care settings in high-income countries reporting on the appropriateness of antibiotic prescriptions. The quality of the studies was evaluated using the Appraisal tool for Cross-Sectional Studies and the Newcastle-Ottawa Scale. Pooled ORs were calculated using random-effects models. Meta-regression, sensitivity and subgroup analysis were also performed. RESULTS We included 40 articles reporting on 30 different factors and their association with inappropriate antibiotic prescribing. 'Appropriateness' covered a wide range of definitions. The following factors were associated with increased inappropriate antibiotic prescribing: acute otitis media diagnosis [pooled OR (95% CI): 2.02 (0.54-7.48)], GP [pooled OR (95% CI) 1.38 (1.00-1.89)] and rural setting [pooled OR (95% CI) 1.47 (1.08-2.02)]. Older patient age and a respiratory tract infection diagnosis have a tendency to be positively associated with inappropriate antibiotic prescribing, but pooling of studies was not possible. CONCLUSIONS Prioritizing acute otitis media, GPs, rural areas, older children and respiratory tract infections within antimicrobial stewardship programmes plays a vital role in promoting responsible antibiotic prescribing. The implementation of a standardized definition of appropriateness is essential to evaluate such programmes.
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Affiliation(s)
- Hannelore Dillen
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
| | - Jo Wouters
- Faculty of Medicine, KU Leuven, 49 Herestraat, Leuven, 3000, Belgium
| | - Daniëlle Snijders
- Faculty of Medicine, KU Leuven, 49 Herestraat, Leuven, 3000, Belgium
| | - Laure Wynants
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- Department of Epidemiology, CAPHRI Care and Public Health Research Institute, Maastricht University, 1 Peter Debyeplein, Maastricht, 6229 HA, The Netherlands
- Department of Development and Regeneration, KU Leuven, 49 Herestraat, Leuven, 3000, Belgium
| | - Jan Y Verbakel
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- NIHR Community Healthcare MedTech and IVD cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
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Rodgers O, Mills C, Watson C, Waterfield T. Role of diagnostic tests for sepsis in children: a review. Arch Dis Child 2024:archdischild-2023-325984. [PMID: 38262696 DOI: 10.1136/archdischild-2023-325984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/10/2024] [Indexed: 01/25/2024]
Abstract
Paediatric sepsis has a significant global impact and highly heterogeneous clinical presentation. The clinical pathway encompasses recognition, escalation and de-escalation. In each aspect, diagnostics have a fundamental influence over outcomes in children. Biomarkers can aid in creating a larger low-risk group of children from those in the clinical grey area who would otherwise receive antibiotics 'just in case'. Current biomarkers include C reactive protein and procalcitonin, which are limited in their clinical use to guide appropriate and rapid treatment. Biomarker discovery has focused on single biomarkers, which, so far, have not outperformed current biomarkers, as they fail to recognise the complexity of sepsis. The identification of multiple host biomarkers that may form a panel in a clinical test has the potential to recognise the complexity of sepsis and provide improved diagnostic performance. In this review, we discuss novel biomarkers and novel ways of using existing biomarkers in the assessment and management of sepsis along with the significant challenges in biomarker discovery at present. Validation of biomarkers is made less meaningful due to methodological heterogeneity, including variations in sepsis diagnosis, biomarker cut-off values and patient populations. Therefore, the utilisation of platform studies is necessary to improve the efficiency of biomarkers in clinical practice.
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Affiliation(s)
- Oenone Rodgers
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Clare Mills
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Chris Watson
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Thomas Waterfield
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast School of Medicine, Dentistry and Biomedical Sciences, Belfast, UK
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Smith AB, Tselenti E, Kanabar D, Miles L. Development of an observer-reported outcome measure to capture the signs and impact of fever distress symptoms in infants and young children. Qual Life Res 2022; 31:1573-1585. [PMID: 34993744 DOI: 10.1007/s11136-021-03049-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE This qualitative study aimed to construct an observer-reported outcome measure (ObsRO) to evaluate fever distress in young children. METHODS A literature review was conducted to identify fever-related concepts. Clinical experts were interviewed for feedback on these concepts. Parents of young children were interviewed to identify behaviours the child exhibited during a recent fever episode. Fever sign and behaviour concepts endorsed by ≥ 20% parents were used to create items for the draft ObsRO. Parents of young children who recently had fever completed the ObsRO and gave feedback during two successive rounds of cognitive interviews. RESULTS Twenty-five parents participated in the concept elicitation. Mean child age was 2.7 years (range: 0.6-5.8 years). Fever sign and behaviour concepts endorsed by ≥ 20% participants were high temperature (80%), skin hot to touch (32%), skin redness/flushing (32%), reduced appetite/drink (96%), needy/clingy/irritable (48-92%), less active/interactive (68-84%) and lethargic (64-88%). Eighteen items, four in the Fever Signs Module and 14 in the Fever Behaviours Module, were developed for the draft ObsRO. Chosen recall period was 24 h. Thirty participants (Round 1: n = 17; Round 2: n = 13), participated in cognitive interviews. Mean child age was 2.4 years (range 0.3-5.8). Round 1 feedback resulted in two Fever Signs items being combined. Three Fever Behaviour items were deleted, six revised and four unchanged. No changes were made following Round 2 feedback. Most participants understood all aspects of the ObsRO and found it user-friendly. CONCLUSION The ObsRO will undergo further development in validation studies testing measurement properties of each item.
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Affiliation(s)
- Adam B Smith
- Health Outcomes, Reckitt Benckiser Healthcare, Dansom Lane, Hull, HU8 7DS, UK.
| | - Evi Tselenti
- Health Outcomes, Reckitt Benckiser Healthcare, Dansom Lane, Hull, HU8 7DS, UK
| | - Dipak Kanabar
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Lisa Miles
- New Platforms, Reckitt Benckiser, Slough, UK
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Verbakel JYJ, De Burghgraeve T, Van den Bruel A, Coenen S, Anthierens S, Joly L, Laenen A, Luyten J, De Sutter A. Antibiotic prescribing rate after optimal near-patient C-reactive protein testing in acutely ill children presenting to ambulatory care (ARON project): protocol for a cluster-randomized pragmatic trial. BMJ Open 2022; 12:e058912. [PMID: 34980633 PMCID: PMC8724812 DOI: 10.1136/bmjopen-2021-058912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Children become ill quite often, mainly because of infections, most of which can be managed in the community. Many children are prescribed antibiotics which contributes to antimicrobial resistance and reinforces health-seeking behaviour. Point-of-care C reactive protein (POC CRP) testing, prescription guidance and safety-netting advice can help safely reduce antibiotic prescribing to acutely ill children in ambulatory care as well as save costs at a systems level. METHODS AND ANALYSIS The ARON (Antibiotic prescribing Rate after Optimal Near-patient testing in acutely ill children in ambulatory care) trial is a pragmatic cluster randomized controlled superiority trial with a nested process evaluation and will assess the clinical and cost effectiveness of a diagnostic algorithm, which includes a standardised clinical assessment, a POC CRP test, and safety-netting advice, in acutely ill children aged 6 months to 12 years presenting to ambulatory care. The primary outcome is antibiotic prescribing at the index consultation; secondary outcomes include clinical recovery, reconsultation, referral/admission to hospital, additional testing, mortality and patient satisfaction. We aim to recruit a total sample size of 6111 patients. All outcomes will be analysed according to the intent-to-treat approach. We will use a mixed-effect logistic regression analysis to account for the clustering at practice level. ETHICS AND DISSEMINATION The study will be conducted in compliance with the principles of the Declaration of Helsinki (current version), the principles of Good Clinical Practice and in accordance with all applicable regulatory requirements. Ethics approval for this study was obtained on 10 November 2020 from the Ethics Committee Research of University Hospitals Leuven under reference S62005. We will ensure that the findings of the study will be disseminated to relevant stakeholders other than the scientific world including the public, healthcare providers and policy-makers. The process evaluation that is part of this trial may provide a basis for an implementation strategy. If our intervention proves to be clinically and cost-effective, it will be essential to educate physicians about introducing the diagnostic algorithm including POC CRP testing and safety-netting advice in their daily practice. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT04470518. Protocol V.2.0 date 2 October 2020. (Pre-results).
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Affiliation(s)
- Jan Yvan Jos Verbakel
- Department of Public Health and Primary Care, Academic Centre for General Practice, EPI-Centre, KU Leuven, Leuven, Belgium
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tine De Burghgraeve
- Department of Public Health and Primary Care, Academic Centre for General Practice, EPI-Centre, KU Leuven, Leuven, Belgium
| | - Ann Van den Bruel
- Department of Public Health and Primary Care, Academic Centre for General Practice, EPI-Centre, KU Leuven, Leuven, Belgium
| | - Samuel Coenen
- Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Wilrijk, Belgium
- Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Sibyl Anthierens
- Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Wilrijk, Belgium
- Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Louise Joly
- Research Unit Primary Care and Health, Department of General Practice, Department of Clinical Sciences, University of Liege, Liege, Belgium
| | - Annouschka Laenen
- Leuven Biostatistics and Statistical Bioinformatics Centre (L-BioStat), KU Leuven, Leuven, Belgium
| | - Jeroen Luyten
- Leuven Institute for Healthcare Policy, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - An De Sutter
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Department of Family Medicine & Health Policy, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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7
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Dillen H, Burvenich R, De Burghgraeve T, Verbakel JY. Using Belgian pharmacy dispensing data to assess antibiotic use for children in ambulatory care. BMC Pediatr 2022; 22:12. [PMID: 34980037 PMCID: PMC8720940 DOI: 10.1186/s12887-021-03047-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 11/30/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The desired effect of antibiotics is compromised by the rapid escalation of antimicrobial resistance. Children are particularly at high-risk for unnecessary antibiotic prescribing, which is owing to clinicians' diagnostic uncertainty combined with parents' concerns and expectations. Recent Belgian data on ambulatory antibiotic prescribing practices for children are currently lacking. Therefore, we aim to analyse different aspects of antibiotic prescriptions for children in ambulatory care. METHODS Pharmacy dispensing data on antibiotics for systematic use referring from 2010 to 2019 were retrieved from Farmanet, a database of pharmaceutical dispensations in community pharmacies. Population data were obtained from the Belgian statistical office (Statbel). Descriptive statistics were performed in Microsoft Excel. The Mann-Kendall test for trend analysis and the seasplot function for seasonality testing were conducted in R. RESULTS The past decade, paediatric antibiotic use and expenditures have relatively decreased in Belgian ambulatory care with 35.5% and 44.3%, respectively. The highest volumes of antibiotics for children are prescribed by GPs working in Walloon region and rural areas, to younger children, and during winter. The most prescribed class of antibiotics for children are the penicillins and the biggest relative reduction in number of packages is seen for the sulfonamides and trimethoprim and quinolone antibacterials. CONCLUSIONS Paediatric antibiotic use has decreased in Belgian ambulatory care. Further initiatives are needed to promote prudent antibiotic prescribing in ambulatory care.
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Affiliation(s)
- Hannelore Dillen
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 7, 3000, Leuven, Belgium.
| | - Ruben Burvenich
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 7, 3000, Leuven, Belgium
| | - Tine De Burghgraeve
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 7, 3000, Leuven, Belgium
| | - Jan Y Verbakel
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 7, 3000, Leuven, Belgium.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford, OX26GG, UK
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van der Velden FJS, Gennery AR, Emonts M. Biomarkers for Diagnosing Febrile Illness in Immunocompromised Children: A Systematic Review of the Literature. Front Pediatr 2022; 10:828569. [PMID: 35372147 PMCID: PMC8965604 DOI: 10.3389/fped.2022.828569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/25/2022] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE This study aims to assess the performance of biomarkers used for the prediction of bacterial, viral, and fungal infection in immunocompromised children upon presentation with fever. METHODS We performed a literature search using PubMed and MEDLINE and In-Process & Other Non-indexed Citations databases. Cohort and case-control studies assessing biomarkers for the prediction of bacterial, viral, or fungal infection in immunocompromised children vs. conventional microbiological investigations were eligible. Studies including adult patients were eligible if pediatric data were separately assessable. Data on definitions used for infections, fever, and neutropenia and predictive values were collected. Risk of bias was assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. RESULTS Fifty-two studies involving 13,939 febrile episodes in 7,059 children were included. In total, 92.2% were in cancer patients (n = 48), and 15.7% also included hematopoietic stem cell transplantation patients (n = 8). Forty-three biomarkers were investigated, of which 6 (CRP, PCT, IL-8, IL-6, IL-10, and TNFα) were significantly associated with bacterial infection at admission, studied in multiple studies, and provided predictive data. Literature on the prediction of viral and fungal infection was too limited. Eight studies compared C-reactive protein (CRP) and procalcitonin (PCT), with PCT demonstrating superiority in 5. IL-6, IL-8, and IL-10 were compared with CRP in six, four, and one study, respectively, with mixed results on diagnostic superiority. No clear superior biomarker comparing PCT vs. IL-6, IL-8, or IL-10 was identified. DISCUSSION There is great heterogeneity in the biomarkers studied and cutoff values and definitions used, thus complicating the analysis. Literature for immunocompromised children with non-malignant disease and for non-bacterial infection is sparse. Literature on novel diagnostics was not available. We illustrated the challenges of diagnosing fever adequately in this study population and the need for improved biomarkers and clinical decision-making tools.
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Affiliation(s)
- Fabian J S van der Velden
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.,Great North Children's Hospital, Paediatric Immunology, Infectious Diseases and Allergy, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Andrew R Gennery
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.,Great North Children's Hospital, Paediatric Immunology, Infectious Diseases and Allergy, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Marieke Emonts
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.,Great North Children's Hospital, Paediatric Immunology, Infectious Diseases and Allergy, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
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Urbane UN, Petrosina E, Zavadska D, Pavare J. Integrating Clinical Signs at Presentation and Clinician's Non-analytical Reasoning in Prediction Models for Serious Bacterial Infection in Febrile Children Presenting to Emergency Department. Front Pediatr 2022; 10:786795. [PMID: 35547543 PMCID: PMC9082163 DOI: 10.3389/fped.2022.786795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Development and validation of clinical prediction model (CPM) for serious bacterial infections (SBIs) in children presenting to the emergency department (ED) with febrile illness, based on clinical variables, clinician's "gut feeling," and "sense of reassurance. MATERIALS AND METHODS Febrile children presenting to the ED of Children's Clinical University Hospital (CCUH) between April 1, 2017 and December 31, 2018 were enrolled in a prospective observational study. Data on clinical signs and symptoms at presentation, together with clinician's "gut feeling" of something wrong and "sense of reassurance" were collected as candidate variables for CPM. Variable selection for the CPM was performed using stepwise logistic regression (forward, backward, and bidirectional); Akaike information criterion was used to limit the number of parameters and simplify the model. Bootstrapping was applied for internal validation. For external validation, the model was tested in a separate dataset of patients presenting to six regional hospitals between January 1 and March 31, 2019. RESULTS The derivation cohort consisted of 517; 54% (n = 279) were boys, and the median age was 58 months. SBI was diagnosed in 26.7% (n = 138). Validation cohort included 188 patients; the median age was 28 months, and 26.6% (n = 50) developed SBI. Two CPMs were created, namely, CPM1 consisting of six clinical variables and CPM2 with four clinical variables plus "gut feeling" and "sense of reassurance." The area under the curve (AUC) for receiver operating characteristics (ROC) curve of CPM1 was 0.744 (95% CI, 0.683-0.805) in the derivation cohort and 0.692 (95% CI, 0.604-0.780) in the validation cohort. AUC for CPM2 was 0.783 (0.727-0.839) and 0.752 (0.674-0.830) in derivation and validation cohorts, respectively. AUC of CPM2 in validation population was significantly higher than that of CPM1 [p = 0.037, 95% CI (-0.129; -0.004)]. A clinical evaluation score was derived from CPM2 to stratify patients in "low risk," "gray area," and "high risk" for SBI. CONCLUSION Both CPMs had moderate ability to predict SBI and acceptable performance in the validation cohort. Adding variables "gut feeling" and "sense of reassurance" in CPM2 improved its ability to predict SBI. More validation studies are needed for the assessment of applicability to all febrile patients presenting to ED.
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Affiliation(s)
- Urzula Nora Urbane
- Department of Pediatrics, Riga Stradins University, Riga, Latvia.,Department of Pediatrics, Children's Clinical University Hospital, Riga, Latvia
| | - Eva Petrosina
- Statistics Unit, Riga Stradins University, Riga, Latvia
| | - Dace Zavadska
- Department of Pediatrics, Riga Stradins University, Riga, Latvia.,Department of Pediatrics, Children's Clinical University Hospital, Riga, Latvia
| | - Jana Pavare
- Department of Pediatrics, Riga Stradins University, Riga, Latvia.,Department of Pediatrics, Children's Clinical University Hospital, Riga, Latvia
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Leigh S, Robinson J, Yeung S, Coenen F, Carrol ED, Niessen LW. 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. Arch Dis Child 2020; 105:765-771. [PMID: 32107251 PMCID: PMC7392496 DOI: 10.1136/archdischild-2019-318209] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 01/08/2023]
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.
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Affiliation(s)
- Simon Leigh
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Jude Robinson
- School of Social and Political Sciences, University of Glasgow, Glasgow, UK
| | - Shunmay Yeung
- Department of Clinical Research, MARCH Centre for Maternal, Adolescent, Reproductive and Child Health, LSHTM, London, UK
| | - Frans Coenen
- Department of Computer Science, University of Liverpool, Liverpool, Merseyside, UK
| | - Enitan D Carrol
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Louis W Niessen
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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11
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Verbakel JY, Lee JJ, Goyder C, Tan PS, Ananthakumar T, Turner PJ, Hayward G, Van den Bruel A. Impact of point-of-care C reactive protein in ambulatory care: a systematic review and meta-analysis. BMJ Open 2019; 9:e025036. [PMID: 30782747 PMCID: PMC6361331 DOI: 10.1136/bmjopen-2018-025036] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 11/02/2018] [Accepted: 12/12/2018] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The aim of this review was to collate all available evidence on the impact of point-of-care C reactive protein (CRP) testing on patient-relevant outcomes in children and adults in ambulatory care. DESIGN This was a systematic review to identify controlled studies assessing the impact of point-of-care CRP in patients presenting to ambulatory care services. Ovid Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane CENTRAL, DARE, Science Citation Index were searched from inception to March 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Controlled studies assessing the impact of point-of-care CRP in patients presenting to ambulatory care services, measuring a change in clinical care, including but not limited to antibiotic prescribing rate, reconsultation, clinical recovery, patient satisfaction, referral and additional tests. No language restrictions were applied. DATA EXTRACTION Data were extracted on setting, date of study, a description of the intervention and control group, patient characteristics and results. Methodological quality of selected studies and assessment of potential bias was assessed independently by two authors using the Cochrane Risk of Bias tool. RESULTS 11 randomised controlled trials and 8 non-randomised controlled studies met the inclusion criteria, reporting on 16 064 patients. All included studies had a high risk of performance and selection bias. Compared with usual care, point-of-care CRP reduces immediate antibiotic prescribing (pooled risk ratio 0.81; 95% CI 0.71 to 0.92), however, at considerable heterogeneity (I2=72%). This effect increased when guidance on antibiotic prescribing relative to the CRP level was provided (risk ratios of 0.68; 95% CI 0.63 to 0.74 in adults and 0.56; 95% CI 0.33 to 0.95 in children). We found no significant effect of point-of-care CRP testing on patient satisfaction, clinical recovery, reconsultation, further testing and hospital admission. CONCLUSIONS Performing a point-of-care CRP test in ambulatory care accompanied by clinical guidance on interpretation reduces the immediate antibiotic prescribing in both adults and children. As yet, available evidence does not suggest an effect on other patient outcomes or healthcare processes. PROSPERO REGISTRATION NUMBER CRD42016035426; Results.
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Affiliation(s)
- Jan Y Verbakel
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Department of Public Health and Primary Care, KU Leuven (University of Leuven), Leuven, Belgium
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Joseph J Lee
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Clare Goyder
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Pui San Tan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Thanusha Ananthakumar
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Philip J Turner
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Ann Van den Bruel
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Department of Public Health and Primary Care, KU Leuven (University of Leuven), Leuven, Belgium
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12
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Verbakel JY, Lemiengre MB, De Burghgraeve T, De Sutter A, Aertgeerts B, Bullens DMA, Shinkins B, Van den Bruel A, Buntinx F. Point-of-care C reactive protein to identify serious infection in acutely ill children presenting to hospital: prospective cohort study. Arch Dis Child 2018; 103:420-426. [PMID: 29269559 DOI: 10.1136/archdischild-2016-312384] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 11/28/2017] [Accepted: 11/28/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Acute infection is the most common presentation of children to hospital. A minority of these infections are serious, but early recognition and adequate management are essential. We aimed to develop improved tools to assess children attending ambulatory hospital care, integrating clinical features with point-of-care C reactive protein (CRP). DESIGN Prospective observational diagnostic study. SETTING AND PATIENTS 5517 acutely ill children (1 month-16 years) presenting to 106 paediatricians at six outpatient clinics and six emergency departments in Belgium. INDEX TEST Point-of-care CRP alongside vital signs and objective symptoms measurements. MAIN OUTCOME Hospital admission for >24 hours with a serious infection <5 days after presentation. RESULTS An algorithm was developed consisting of clinical features and CRP. This achieved 97.1% (95% CI 94.3% to 98.7%) sensitivity and 99.6% (95% CI 99.2% to 99.8%) negative predictive value, excluding serious infections in 36.4% of children. It stratifies patients into three groups based on CRP level: high-risk group with CRP >75 mg/L (26.8% risk of infection), intermediate-risk group with CRP 20-75 mg/L and at least one of seven clinical features (8.1%), and lower risk group with CRP <20 mg/L with at least one of the 11 features (3.8%). Children in intermediate-risk or low-risk groups with normal clinical assessment have 0.6% and 0.4% risk of serious infections, respectively. CONCLUSIONS Conducting a CRP test may first enable children to be stratified into three risk groups, guiding assessment of clinical features that could be performed by junior doctors or nurses. In one-third of acutely ill children, the algorithm could exclude serious infection. Prospective validation of the algorithm is needed. CLINICAL TRIAL REGISTRATION NCT02024282 (post-results).
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Affiliation(s)
- Jan Y Verbakel
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Marieke B Lemiengre
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | | | - An De Sutter
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Dominique M A Bullens
- Clinical Department of Paediatrics, University Hospitals Leuven, Leuven, Belgium.,Paediatric Immunology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Bethany Shinkins
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Ann Van den Bruel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Frank Buntinx
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Research Institute CAPHRI, Maastricht University, Maastricht, The Netherlands
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13
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Verbakel JY, Lemiengre MB, De Burghgraeve T, De Sutter A, Aertgeerts B, Shinkins B, Perera R, Mant D, Van den Bruel A, Buntinx F. Should all acutely ill children in primary care be tested with point-of-care CRP: a cluster randomised trial. BMC Med 2016; 14:131. [PMID: 27716201 PMCID: PMC5052874 DOI: 10.1186/s12916-016-0679-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 08/24/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Point-of-care blood C-reactive protein (CRP) testing has diagnostic value in helping clinicians rule out the possibility of serious infection. We investigated whether it should be offered to all acutely ill children in primary care or restricted to those identified as at risk on clinical assessment. METHODS Cluster randomised controlled trial involving acutely ill children presenting to 133 general practitioners (GPs) at 78 GP practices in Belgium. Practices were randomised to undertake point-of-care CRP testing in all children (1730 episodes) or restricted to children identified as at clinical risk (1417 episodes). Clinical risk was assessed by a validated clinical decision rule (presence of one of breathlessness, temperature ≥ 40 °C, diarrhoea and age 12-30 months, or clinician concern). The main trial outcome was hospital admission with serious infection within 5 days. No specific guidance was given to GPs on interpreting CRP levels but diagnostic performance is reported at 5, 20, 80 and 200 mg/L. RESULTS Restricting CRP testing to those identified as at clinical risk substantially reduced the number of children tested by 79.9 % (95 % CI, 77.8-82.0 %). There was no significant difference between arms in the number of children with serious infection who were referred to hospital immediately (0.16 % vs. 0.14 %, P = 0.88). Only one child with a CRP < 5 mg/L had an illness requiring admission (a child with viral gastroenteritis admitted for rehydration). However, of the 80 children referred to hospital to rule out serious infection, 24 (30.7 %, 95 % CI, 19.6-45.6 %) had a CRP < 5 mg/L. CONCLUSIONS CRP testing should be restricted to children at higher risk after clinical assessment. A CRP < 5 mg/L rules out serious infection and could be used by GPs to avoid unnecessary hospital referrals. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02024282 (registered on 14th September 2012).
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Affiliation(s)
- Jan Y Verbakel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Woodstock Road, Oxford, OX2 6GG, UK. .,Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33J, 3000, Leuven, Belgium.
| | - Marieke B Lemiengre
- Department of Family Medicine and Primary Health Care, Ghent University, De Pintelaan 185, Gent, 9000, Belgium
| | - Tine De Burghgraeve
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33J, 3000, Leuven, Belgium
| | - An De Sutter
- Department of Family Medicine and Primary Health Care, Ghent University, De Pintelaan 185, Gent, 9000, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33J, 3000, Leuven, Belgium
| | - Bethany Shinkins
- Leeds Institute of Health Sciences, University of Leeds, 101 Clarendon Road, Leeds, LS29LJ, UK
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Woodstock Road, Oxford, OX2 6GG, UK
| | - David Mant
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Woodstock Road, Oxford, OX2 6GG, UK
| | - Ann Van den Bruel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Woodstock Road, Oxford, OX2 6GG, UK
| | - Frank Buntinx
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33J, 3000, Leuven, Belgium.,Research Institute Caphri, Maastricht University, Universiteitssingel 40, Maastricht, 6229 ER, The Netherlands
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14
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Bertheloot K, Deraeve P, Vermandere M, Aertgeerts B, Lemiengre M, De Sutter A, Buntinx F, Verbakel JY. How do general practitioners use 'safety netting' in acutely ill children? Eur J Gen Pract 2015; 22:3-8. [PMID: 26578087 DOI: 10.3109/13814788.2015.1092516] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND 'Safety netting' advice allows general practitioners (GPs) to cope with diagnostic uncertainty in primary care. It informs patients on 'red flag' features and when and how to seek further help. There is, however, insufficient evidence to support useful choices regarding 'safety netting' procedures. OBJECTIVES To explore how GPs apply 'safety netting' in acutely ill children in Flanders. METHODS We designed a qualitative study consisting of semi-structured interviews with 37 GPs across Flanders. Two researchers performed qualitative analysis based on grounded theory components. RESULTS Although unfamiliar with the term, GPs perform 'safety netting' in every acutely ill child, guided by their intuition without the use of specific guidelines. They communicate 'red flag' features, expected time course of illness and how and when to re-consult and try to tailor their advice to the context, patient and specific illness. Overall, GPs perceive 'safety netting' as an important element of the consultation, acknowledging personal and parental limitations, such as parents' interpretation of their advice. GPs do not feel a need for any form of support in the near future. CONCLUSION GPs apply 'safety netting' intuitively and tailor the content. Further research should focus on the impact of 'safety netting' on morbidity and how the advice is conveyed to parents.
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Affiliation(s)
| | | | | | - Bert Aertgeerts
- a Department of General Practice , KU Leuven , Leuven , Belgium
| | - Marieke Lemiengre
- b Department of Family Practice and Primary Health Care , Ghent University , Gent , Belgium
| | - An De Sutter
- b Department of Family Practice and Primary Health Care , Ghent University , Gent , Belgium
| | - Frank Buntinx
- a Department of General Practice , KU Leuven , Leuven , Belgium ;,c Research Institute Caphri, Maastricht University , Maastricht , The Netherlands
| | - Jan Y Verbakel
- a Department of General Practice , KU Leuven , Leuven , Belgium
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15
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Verbakel JY, Lemiengre MB, De Burghgraeve T, De Sutter A, Aertgeerts B, Bullens DMA, Shinkins B, Van den Bruel A, Buntinx F. Validating a decision tree for serious infection: diagnostic accuracy in acutely ill children in ambulatory care. BMJ Open 2015; 5:e008657. [PMID: 26254472 PMCID: PMC4538259 DOI: 10.1136/bmjopen-2015-008657] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Acute infection is the most common presentation of children in primary care with only few having a serious infection (eg, sepsis, meningitis, pneumonia). To avoid complications or death, early recognition and adequate referral are essential. Clinical prediction rules have the potential to improve diagnostic decision-making for rare but serious conditions. In this study, we aimed to validate a recently developed decision tree in a new but similar population. DESIGN Diagnostic accuracy study validating a clinical prediction rule. SETTING AND PARTICIPANTS Acutely ill children presenting to ambulatory care in Flanders, Belgium, consisting of general practice and paediatric assessment in outpatient clinics or the emergency department. INTERVENTION Physicians were asked to score the decision tree in every child. PRIMARY OUTCOME MEASURES The outcome of interest was hospital admission for at least 24 h with a serious infection within 5 days after initial presentation. We report the diagnostic accuracy of the decision tree in sensitivity, specificity, likelihood ratios and predictive values. RESULTS In total, 8962 acute illness episodes were included, of which 283 lead to admission to hospital with a serious infection. Sensitivity of the decision tree was 100% (95% CI 71.5% to 100%) at a specificity of 83.6% (95% CI 82.3% to 84.9%) in the general practitioner setting with 17% of children testing positive. In the paediatric outpatient and emergency department setting, sensitivities were below 92%, with specificities below 44.8%. CONCLUSIONS In an independent validation cohort, this clinical prediction rule has shown to be extremely sensitive to identify children at risk of hospital admission for a serious infection in general practice, making it suitable for ruling out. TRIAL REGISTRATION NUMBER NCT02024282.
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Affiliation(s)
- Jan Y Verbakel
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Marieke B Lemiengre
- Department of Family Practice and Primary Health Care, Ghent University, Ghent, Belgium
| | | | - An De Sutter
- Department of Family Practice and Primary Health Care, Ghent University, Ghent, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Dominique M A Bullens
- Clinical Department of Paediatrics, University Hospitals Leuven, Leuven, Belgium
- Paediatric Immunology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Bethany Shinkins
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ann Van den Bruel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Frank Buntinx
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Research Institute Caphri, Maastricht University, Maastricht, The Netherlands
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16
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Verbakel JY, Lemiengre MB, De Burghgraeve T, De Sutter A, Bullens DMA, Aertgeerts B, Buntinx F. Diagnosing serious infections in acutely ill children in ambulatory care (ERNIE 2 study protocol, part A): diagnostic accuracy of a clinical decision tree and added value of a point-of-care C-reactive protein test and oxygen saturation. BMC Pediatr 2014; 14:207. [PMID: 25277457 PMCID: PMC4287386 DOI: 10.1186/1471-2431-14-207] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 08/22/2014] [Indexed: 11/16/2022] Open
Abstract
Background Acute illness is the most common presentation of children to ambulatory care. In contrast, serious infections are rare and often present at an early stage. To avoid complications or death, early recognition and adequate referral are essential. In a recent large study children were included prospectively to construct a symptom-based decision tree with a sensitivity and negative predictive value of nearly 100%. To reduce the number of false positives, point-of-care tests might be useful, providing an immediate result at bedside. The most probable candidate is C-reactive protein, as well as a pulse oximetry. Methods This is a diagnostic accuracy study of signs, symptoms and point-of-care tests for serious infections. Acutely ill children presenting to a family physician or paediatrician will be included consecutively in Flanders, Belgium. Children testing positive on the decision tree will get a point-of-care C-reactive protein test. Children testing negative will randomly either receive a point-of-care C-reactive protein test or usual care. The outcome of interest is hospital admission more than 24 hours with a serious infection within 10 days. Aiming to include over 6500 children, we will report the diagnostic accuracy of the decision tree (+/− the point-of-care C-reactive protein test or pulse oximetry) in sensitivity, specificity, positive and negative likelihood ratios, and positive and negative predictive values. New diagnostic algorithms will be constructed through classification and regression tree and multiple logistic regression analysis. Discussion We aim to improve detection of serious infections, and present a practical tool for diagnostic triage of acutely ill children in primary care. We also aim to reduce the number of investigations and admissions in children with non-serious infections. Trial Registration ClinicalTrials.gov Identifier: NCT02024282
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Affiliation(s)
- Jan Y Verbakel
- Department of General Practice, KU Leuven, Kapucijnenvoer 33, 3000 Leuven, Belgium.
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