Method: Pediatric subspecialists (developmental pediatricians, gastroenterologists, pulmonologists, and neonatologists) at a single tertiary care children’s hospital were interviewed about their decision making when referring children with GERD for ARPs. Qualitative analysis was performed on clinicians’ perceptions of the physiological and clinical risks and benefits of the treatment options. Clinical algorithms were derived from each interview. Algorithms were compared using a validated comparison tool--The Clinical Algorithm Nosology (CAN). Clinical Algorithm Structural Analysis (CASA) scores to assess algorithm complexity were calculated based on the number of clinical steps and decisions. Clinical Algorithm Patient Abstraction (CAPA) scores on a scale from 0 (different) to 10 (identical) were generated based on agreement in patient management between two algorithms.
Result: The interviews yielded 15 clinical algorithms. There was substantial variation in the providers’ perceived risks and benefits of the treatment options. Most clinicians considered history of aspiration as an indication for ARP. There was also substantial variation in both the algorithm complexity and patient management. CASA scores ranged from 8-28 indicating large variation in decision algorithm complexity. CAPA scores ranged from 0-5.7 (median score of 0) indicating that when managed by the most similar algorithms, patients would receive the same tests and procedures about half the time.
Conclusion: No standards exist for the decision to refer children with GERD for ARP. There is large variation among pediatric subspecialists in their decision making. Differences in providers’ perception of the risks and benefits of these procedures likely contribute to this variation.