Scholer S J, Pituch K, Orr D P, Clark D, Dittus R S
Department of Pediatrics, Indiana University School of Medicine, the Regenstrief Institute for Health Care, Indianapolis, USA.
Arch Pediatr Adolesc Med. 1996 Nov;150(11):1154-9. doi: 10.1001/archpedi.1996.02170360044006.
To determine the effect of the emergency department (ED) environment and other health care system factors on test ordering for children with acute abdominal pain.
We reviewed the encounter records of 1140 consecutive children seen in either the pediatric clinic or ED of an inner-city teaching hospital with a complaint of acute abdominal pain (< 72 hours). In the ED and the clinic, patients were seen by medical students, pediatric residents, and general pediatric faculty members. Measured data on test ordering included the number of tests ordered and the type of tests ordered; specifically examined were the throat culture, urinalysis or urine culture, and chest radiograph. Measured health care system factors included (1) encounter location; (2) resident involvement and level of training; (3) student involvement; and (4) faculty member's years of experience and sex.
Of the 1140 children, 117 (10.2%) were seen in the ED, 531 (47.1%) were seen by a resident, 344 (30.2%) were seen by a medical student, and 195 (17.1%) were seen by a faculty member with more than 10 years of clinical pediatric experience. After controlling for initial signs and symptoms in multiple logistic regression, a child treated in the ED was no more likely to have had tests ordered than one who was treated in the clinic. Neither resident involvement nor resident training level affected test ordering. Except for decreasing the likelihood of having a urinalysis or urine culture ordered (odds ratio [OR] = 0.30; 95% confidence interval [CI], 0.15-0.63), student involvement did not affect test ordering. Also, except for decreasing the likelihood of having a throat culture ordered (OR = 0.45; 95% CI, 0.25-0.83), being seen by a pediatrician with more than 10 years of experience did not affect test ordering. Children seen by female physicians were more likely (OR = 2.41; 95% CI, 1.57-3.70) to have at least 1 test ordered.
For children seen for a complaint of acute abdominal pain, we found little evidence that test ordering is affected by encounter location, resident involvement, student involvement, or faculty member experience.
确定急诊科（ED）环境及其他医疗保健系统因素对急性腹痛患儿检查医嘱开具的影响。
我们回顾了一家市中心教学医院儿科门诊或急诊科连续就诊的1140例主诉急性腹痛（<72小时）患儿的诊疗记录。在急诊科和门诊，由医学生、儿科住院医师和普通儿科教员为患者看病。检查医嘱开具的测量数据包括开具检查的数量和检查类型；具体检查的项目有咽喉培养、尿液分析或尿培养以及胸部X光片。测量的医疗保健系统因素包括：（1）就诊地点；（2）住院医师参与情况及培训水平；（3）医学生参与情况；（4）教员的临床经验年限和性别。
1140例患儿中，117例（10.2%）在急诊科就诊，531例（47.1%）由住院医师看病，344例（30.2%）由医学生看病，195例（17.1%）由具有超过10年儿科临床经验的教员看病。在多因素逻辑回归中对初始体征和症状进行控制后，在急诊科接受治疗的患儿开具检查的可能性并不比在门诊接受治疗的患儿更高。住院医师的参与情况和培训水平均未影响检查医嘱的开具。除了降低开具尿液分析或尿培养的可能性（比值比[OR]=0.30；95%置信区间[CI]，0.15 - 0.63）外，医学生的参与情况未影响检查医嘱的开具。同样，除了降低开具咽喉培养的可能性（OR = 0.45；95% CI，0.25 - 0.83）外，由具有超过10年经验的儿科医生看病并未影响检查医嘱的开具。由女医生看病的患儿更有可能（OR = 2.41；95% CI，1.57 - 3.70）至少开具一项检查。
对于因急性腹痛主诉就诊的患儿，我们几乎没有发现证据表明检查医嘱的开具受就诊地点、住院医师参与情况、医学生参与情况或教员经验的影响。
