Effect of health care system factors on test ordering
S. J. Scholer, K. Pituch, D. P. Orr, D. Clark and R. S. Dittus
Department of Pediatrics, Indiana University School of Medicine, the Regenstrief Institute for Health Care, Indianapolis, USA.
OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.
