Reeder Brian M, Lyne E Dennis, Patel Dilip R, Cucos Diana R
Department of Pediatrics, Michigan State University-Kalamazoo Center for Medical Studies, Kalamazoo, Michigan 49008, USA.
Pediatrics. 2004 Mar;113(3 Pt 1):e163-7. doi: 10.1542/peds.113.3.e163.
Musculoskeletal medicine is becoming an increasingly essential part of primary care medicine. The American Academy of Pediatrics (AAP) Surgical Advisory Panel recently published voluntary guidelines to establish diagnoses that should be referred to a pediatric specialist rather than a general specialist (pediatric orthopedic surgery vs general orthopedic surgery). Given the crisis in pediatric orthopedic surgery manpower and resources, we believe that these guidelines are useful in defining appropriate referrals. The purpose of this study was to compare diagnoses that primary care pediatric providers believe commonly need referral to the AAP Guidelines for Referral to Pediatric Specialists recommendations for referral to pediatric orthopedic specialists.
A chart review of successive new referrals (n = 286) to the pediatric orthopedic clinic during a 12-month period was conducted. The following information was collected: 1) diagnosis from referring provider, 2) diagnosis and treatment plan by the pediatric orthopedic surgeon, 3) type of referring provider (eg, pediatrician, family practitioner, resident physician, physician assistant), and 4) patient age. The referring diagnosis, final orthopedic diagnosis, and treatment plan for each patient was compared against the AAP Guidelines for Referral to Pediatric Specialists. The terms "appropriate" and "inappropriate" were used to differentiate those diagnoses that matched versus those that did not match the AAP Guidelines, respectively.
This analysis shows that a significant percentage (64.7%) of definitive diagnoses of referred cases were not consistent with the new AAP recommended guidelines for referral to pediatric orthopedic surgeons. In addition, a 23.8% (68 of 286) false-positive rate of referring diagnoses is noted. Cases that required no treatment or follow-up to monitor demonstrated a 32.8% (60 of 183) [(40 no treatment + 20 monitor inappropriate)/(116 no treatment + 67 monitor total)] false-positive rate.
Inappropriate referrals create a large use of pediatric orthopedic resources, which delays care of other, more appropriate patients. A large proportion of referrals indicated either a lack of basic textbook knowledge or lack of examination skills and appropriate diagnostic tools as demonstrated by a high number of definitive diagnosis indicating normal variants.
肌肉骨骼医学正日益成为初级保健医学的重要组成部分。美国儿科学会（AAP）外科咨询小组最近发布了自愿性指南，以确定应转诊至儿科专科医生而非普通专科医生（小儿骨科手术与普通骨科手术）的诊断。鉴于小儿骨科手术人力和资源的危机，我们认为这些指南有助于明确适当的转诊。本研究的目的是比较初级保健儿科提供者认为通常需要转诊的诊断与AAP《儿科专科转诊指南》中关于转诊至小儿骨科专科医生的建议。
对12个月期间连续转诊至小儿骨科诊所的新患者（n = 286）进行病历审查。收集了以下信息：1）转诊提供者的诊断，2）小儿骨科外科医生的诊断和治疗计划，3）转诊提供者的类型（如儿科医生、家庭医生、住院医师、医师助理），以及4）患者年龄。将每位患者的转诊诊断、最终骨科诊断和治疗计划与AAP《儿科专科转诊指南》进行比较。分别使用“适当”和“不适当”来区分与AAP指南相符和不相符的诊断。
该分析表明，转诊病例的最终诊断中有很大比例（64.7%）与AAP推荐的转诊至小儿骨科外科医生的新指南不一致。此外，转诊诊断的假阳性率为23.8%（286例中的68例）。无需治疗或随访监测的病例的假阳性率为32.8%（183例中的60例）[（40例无需治疗 + 20例监测不适当）/（116例无需治疗 + 67例监测总数）]。
不适当的转诊导致小儿骨科资源的大量使用，从而延误了其他更合适患者的治疗。很大一部分转诊表明要么缺乏基本的教科书知识，要么缺乏检查技能和适当的诊断工具，大量最终诊断显示为正常变异就是证明。
