Kramer M S, Etezadi-Amoli J, Ciampi A, Tange S M, Drummond K N, Mills E L, Bernstein M L, Leduc D G
Department of Pediatrics, McGill University Faculty of Medicine, Montreal, Quebec.
Pediatrics. 1994 May;93(5):697-702.
To compare how parents and physicians value potential clinical outcomes in young children who have a fever but no focus of bacterial infection.
Cross-sectional study of 100 parents of well children aged 3 to 24 months, 61 parents of febrile children aged 3 to 24 months, and 56 attending staff physicians working in a children's hospital emergency department. A pretested visual analog scale was used to assess values on a 0-to-1 scale (where 0 is the value of the worst possible outcome, and 1 is the value for the best) for 22 scenarios, grouped in three categories according to severity. Based on the three or four common attributes comprising the scenarios in a given group, each respondent's value function was estimated statistically based on multiattribute utility theory.
For outcomes in group 1 (rapidly resolving viral infection with one or more diagnostic tests), no significant group differences were observed. For outcomes in groups 2 (acute infections without long-term sequelae) and 3 (long-term sequelae of urinary tract infection or bacterial meningitis), parents of well children and parents of febrile children had values that were similar to each other but significantly lower than physicians' values for pneumonia with delayed diagnosis, false-positive diagnosis of urinary tract infection, viral meningitis, and unilateral hearing loss. For bacterial meningitis with or without delay, however, the reverse pattern was observed; physicians' values were lower than parents'. In arriving at their judgment for group 2 and 3 scenarios, parents gave significantly greater weight to attributes involving the pain and discomfort of diagnostic tests and to diagnostic error, whereas physicians gave significantly greater weight to attributes involving both short- and long-term morbidity and long-term worry and inconvenience. Parents were significantly more likely to be risk-seeking in the way they weighted the attributes comprising group 2 and 3 scenarios than physicians, ie, they were more willing to risk rare but severe morbidity to avoid the short-term adverse effects of testing.
Parents and physicians show fundamental value differences concerning diagnostic testing, diagnostic error, and short- and long-term morbidity; these differences have important implications for diagnostic decision making in the young febrile child.
比较家长和医生对发热但无细菌感染病灶的幼儿潜在临床结局的重视程度。
对100名3至24个月健康儿童的家长、61名3至24个月发热儿童的家长以及56名在儿童医院急诊科工作的主治医师进行横断面研究。使用经过预测试的视觉模拟量表，在0至1的量表上评估22种情况的重视程度（其中0代表最差可能结局的重视程度，1代表最佳结局的重视程度），这些情况根据严重程度分为三类。根据给定组中构成情况的三或四个共同属性，基于多属性效用理论对每位受访者的重视程度函数进行统计估计。
对于第1组结局（通过一项或多项诊断测试迅速缓解的病毒感染），未观察到显著的组间差异。对于第2组结局（无长期后遗症的急性感染）和第3组结局（尿路感染或细菌性脑膜炎的长期后遗症），健康儿童的家长和发热儿童的家长的重视程度彼此相似，但显著低于医生对肺炎延迟诊断、尿路感染假阳性诊断、病毒性脑膜炎和单侧听力损失的重视程度。然而，对于有或无延迟的细菌性脑膜炎，观察到相反的模式；医生的重视程度低于家长。在对第2组和第3组情况做出判断时，家长对涉及诊断测试的疼痛和不适以及诊断错误的属性给予了显著更高的权重，而医生对涉及短期和长期发病率以及长期担忧和不便的属性给予了显著更高的权重。与医生相比，家长在权衡构成第2组和第3组情况的属性时更有可能寻求风险，即他们更愿意冒罕见但严重发病的风险来避免测试的短期不良影响。
家长和医生在诊断测试、诊断错误以及短期和长期发病率方面表现出根本的重视程度差异；这些差异对发热幼儿的诊断决策具有重要意义。
