Diagnostic test ordering in the evaluation of febrile children. Physician and environmental factors
D. L. McGillivray, R. Roberts-Brauer and M. S. Kramer
Department of Pediatrics, McGill University Faculty of Medicine, Montreal, Quebec, Canada.
OBJECTIVE--To assess the independent effects of physician and environmental
factors on test ordering. METHODS--We prospectively studied 6191
consecutive visits by nonadmitted febrile (rectal temperature > or =
38.0 degrees C) children less than 18 years of age to a children's hospital
emergency department from March through November 1989. Multiple logistic
regression analysis was used to control for the mutually confounding
effects of patient, physician, and environmental factors and to assess
attending staff-trainee interactions (effect modification).
RESULTS--Patients evaluated by hospital-based subspecialists were
significantly more likely to undergo tests than patients evaluated by
community-based physicians (odds ratio [OR] for undergoing at least one
test, 1.13; 95% confidence interval [CI], 1.04 to 1.23; OR for complete
blood cell count, 1.28; 95% CI, 1.12 to 1.46). Children seen by physicians
with more than 10 years of experience were significantly less likely to
undergo tests than those seen by their more junior colleagues, but this
effect was modified substantially by trainee presence and level. For
example, when children were seen by a physician with more than 10 years of
experience and no trainee was involved, the OR for undergoing at least one
test was 0.81 (95% CI, 0.73 to 0.91). If the same physician saw the same
patient with a junior trainee, the OR for undergoing at least one test was
1.08 (95% CI, 0.95 to 1.24). Patients seen between July and November were
significantly more likely to undergo at least one test than those seen
between March and June (OR, 1.28; 95% CI, 1.20 to 1.36).
CONCLUSIONS--Attending staff, trainee, and seasonal effects on test
ordering have important implications for febrile children and their
families, for clinical training and supervision, and for health care costs.
