Gold Jessica, Hametz Patricia, Sen Anita I, Maykowski Philip, Leone Nicole, Lee Diana S, Gagliardo Christina, Hymes Saul, Biller Rachel, Saiman Lisa
Morgan Stanley Children's Hospital, Columbia University Medical Center and
Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, New York.
Hosp Pediatr. 2019 Feb;9(2):87-91. doi: 10.1542/hpeds.2018-0211. Epub 2019 Jan 4.
Practice guidelines have been published for bronchiolitis and community-acquired pneumonia (CAP), but little is known about pediatricians' knowledge of and attitudes toward these guidelines since their publication.
We surveyed pediatric providers at 6 children's hospitals in the New York City area. Two vignettes, an infant with bronchiolitis and a child with CAP, were provided, and respondents were asked about management. Associations between respondent characteristics and their reported practices were examined using χ and Fisher's exact tests. Associations between questions probing knowledge and attitude barriers relevant to guideline adherence and reported practices were examined using Cochran-Mantel-Haenszel relative risk estimates.
Of 283 respondents, 58% were trainees; 57% of attending physician respondents had finished training within 10 years. Overall, 76% and 45% of respondents reported they had read the bronchiolitis and CAP guidelines, respectively. For the bronchiolitis vignette, 40% reported ordering a chest radiograph (CXR), and 38% prescribed bronchodilators (neither recommended). For the CAP vignette, 38% prescribed ceftriaxone (not recommended). Study site, level of training, and practice locations were associated with nonrecommended practices. Site-adjusted knowledge and attitude barriers were used to identify that those who agreed CXRs were useful in managing bronchiolitis were more likely to order CXRs, and those who felt bronchodilators shortened length of stay were more likely to prescribe them. Concerns about ampicillin resistance and lack of confidence using local susceptibility patterns to guide prescribing were associated with ordering ceftriaxone.
Provider-level factors and knowledge gaps were associated with ordering nonrecommended treatments for bronchiolitis and CAP.
针对细支气管炎和社区获得性肺炎（CAP）已发布了实践指南，但自这些指南发布以来，对于儿科医生对其的了解程度和态度知之甚少。
我们对纽约市地区6家儿童医院的儿科医疗服务提供者进行了调查。提供了两个病例 vignettes，一个是患细支气管炎的婴儿，另一个是患CAP的儿童，并询问受访者的管理方法。使用χ检验和费舍尔精确检验来检查受访者特征与其报告的做法之间的关联。使用 Cochr an-Mantel-Haenszel相对风险估计来检查与指南依从性相关的知识和态度障碍问题与报告的做法之间的关联。
在283名受访者中，58%是实习生；57%的主治医师受访者在10年内完成了培训。总体而言，分别有76%和45%的受访者报告称他们阅读过细支气管炎和CAP指南。对于细支气管炎病例 vignette，40%的人报告开具了胸部X光片（CXR），38%的人开具了支气管扩张剂（均不推荐）。对于CAP病例 vignette，38%的人开具了头孢曲松（不推荐）。研究地点、培训水平和执业地点与不推荐的做法有关。经地点调整的知识和态度障碍被用于确定那些认为CXR对管理细支气管炎有用的人更有可能开具CXR，以及那些认为支气管扩张剂可缩短住院时间的人更有可能开具它们。对氨苄西林耐药性的担忧以及缺乏使用当地药敏模式指导处方的信心与开具头孢曲松有关。
医疗服务提供者层面的因素和知识差距与开具针对细支气管炎和CAP的不推荐治疗方法有关。
