Referring physicians' decision making for pediatric anti-reflux procedures.
BACKGROUND
Rates of anti-reflux procedures (ARP) vary greatly among pediatric hospitals. How pediatric subspecialists make referral decisions for ARPs has not been described. The aim of this study was to characterize pediatric subspecialists' decision making for referring children for ARPs.


METHODS
Pediatric subspecialists at a single children's hospital were interviewed about their decision making when referring for ARPs. Qualitative analysis was performed on clinicians' perceptions of the risks and benefits of the treatment options. Clinical algorithms were derived from each interview and were compared using the Clinical Algorithm Nosology. Clinical Algorithm Structural Analysis (CASA) scores were calculated to assess algorithm complexity. Clinical Algorithm Patient Abstraction (CAPA) scores on a scale from 0 (different) to 10 (identical) were generated based on algorithm agreement.


RESULTS
The interviews yielded 15 algorithms. There was substantial variation in the providers' perceived risks and benefits of the treatment options. CASA scores ranged from 8 to 28 and CAPA scores ranged from 0 to 5.7 (median, 0), indicating great variation in both complexity and patient management. Management variation included testing (33% of algorithms incorporated pH probe test, 67% upper gastrointestinal, and 47% small bowel follow-through), procedure contraindications (33% considered history of gagging a contraindication to ARP), and use of gastrojejunostomy tubes (20% using gastrojejunostomy tube before ARP).


CONCLUSIONS
No standards exist for the decision to refer children with gastroesophageal reflux disease for ARP. There is great variation among pediatric subspecialists in their decision making. Differences in providers' perception of the risks and benefits of these procedures contribute to this variation.
Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. Electronic address: papi0011@umn.edu.
Jonathan C
JC
Papic
Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN.
S Maria E
SM
Finnell
Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN.
Charles M
CM
Leys
Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN; Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN.
William E
WE
Bennett
Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN; Regenstrief Institute, Inc, Indianapolis, IN.
Stephen M
SM
Downs
D000293:Adolescent; D000465:Algorithms; D002648:Child; D002675:Child, Preschool; D013505:Digestive System Surgical Procedures; D019468:Disease Management; D050782:Esophageal pH Monitoring; D015390:Gastric Bypass; D005764:Gastroesophageal Reflux / Q000175:diagnosis* / Q000628:therapy*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D010818:Practice Patterns, Physicians'; D012017:Referral and Consultation; D018570:Risk Assessment