All that wheezes is confusing: particularly between the ages of 1 and 2

Transcription

1 All that wheezes is confusing: particularly between the ages of 1 and 2 Department of Primary Health Care and General Practice University of Otago Wellington New Zealand Tony Dowell Department of Primary Health Care and General Practice Wellington School of Medicine and Health Sciences

2 This afternoon Presentation on behalf of: Tony Dowell, Lynn McBain, Jayden MacCrae, Olivia Jones, Ben Darlow, Nikki Turner A look at childhood illness A description of a methodology A conundrum about wheezing

3 How is Primary Care doing in Child Health? In this debate everything that everyone says will be true, no matter how opposed their views. Resolving this contradiction for the good of the people is our life s work. Senator Facilibrus Address to the Roman Senate - 32 BCE

4 The state of play Well, the GPs seem to send in all these kids with bronchiolitis and a whole lot more present straight to ED; part of the problem is winter DHB planner and funder They have to come all the way from Porirua to Wellington and then get admitted through ED, because there is no out of hours access Paediatrician

5 Childhood morbidity High workload (0-5 years 6 + visits / yr) Unclear how much actual illness or morbidity Much illness acute and self limiting Not coded General Practice and Primary care contribution unrecognised Kids Ambulatory Sensitive Hospitalisations = a lot of hospital admissions

6 The sharp and pointy end of child health Should Bethany go to hospital? 14 months old - Onset of difficulty breathing and wheeze Smoking household. Damp house, poor nutrition Anxious Solo mum Seen at GP Wheezy infant, Feeding less than usual Apyrexial, Resp rate 35, HR 120, Wheezing. Intercostal indrawing

7 Should Bethany go to hospital Discussed with Paediatric Reg. I think she can probably stay at home, there s a four hour wait in ED Observe / stay at Aunties Wheezing worse Unable to afford After Hours Discharge code Bronchiolitis => ED

8 Ambulatory Sensitive Hospitalisations in Children Aged 0 4 Years by Primary Diagnosis, New Zealand Primary Diagnosis Number: Total Number: Annual Average New Zealand Ambulatory Sensitive Hospitalisations 0 4 Years Emergency Department Cases Included Rate per 1,000 Percent (%) Gastroenteritis 21,329 4, Acute Upper Respiratory Tract Infections 15,595 3, Asthma 15,511 3, Dental Conditions 13,261 2, Bacterial/Non-Viral Pneumonia 10,898 2, Skin Infections 7,743 1, Otitis Media 2, Dermatitis and Eczema 2, Constipation 1, Gastro-Oesophageal Reflux 1, Bronchiectasis Nutritional Disorders VPD 6 Months: DTP, Polio, HepB VPD 16 Months: MMR Rheumatic Fever/Heart Disease New Zealand Total 92,728 18,

9 2 3 fold variation Who Cares?

10 Prevalence of Childhood morbidity patterns? Interrogate PMS systems Prevalence and utilisation data The project

11 Method 36 Primary Care practices and After Hours / ED data Networks of 2 PHOs All Doctor consultations children <18 1 Jan Dec 2013 N= 754,242 Coded data and free text from patient notes

12 Free text - Get a crawler trawler Natural Language processor Develop clinical algorithms for different conditions Computer software that identifies language patterns and keywords in descriptions of symptoms. Childhood respiratory illness Also skin infections and injury

13 Creating the data set Data extracted from PMS using automated query extraction => PHO / research team Algorithm development and training 1. Creating the respiratory condition categories 2. Getting a Gold Standard 3. Informing the algorithm 4. Training the algorithm 5. Testing and validating the algorithm

14 1. Creating respiratory condition categories

15 Respiratory conditions

16 What is already coded? Up to 24% of the 553 respiratory consultations identified by expert clinicians

17 12 practices (10 GP 2 AHC) 1193 notes reviewed separately by 2 GPs Diagnoses classified and defined 2. A gold standard

18 What is seen 1200 consultations

19 Informing and training 3. Informing the algorithm For each classification sensitivity, specificity, PPV Calculated within the training set Data compared with existing evidence Informs weight given to each symptom by the software 4. Training the algorithm 10 rounds of training by non clinical analyst Improve specificity => conservative estimate

20 Interim Test set different set of random selected notes 1200 Second set of clinician classification

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23 Back to wheezing Hippocrates ; spasm linked to asthma were more likely to occur among anglers, tailors and metalworkers. Maimonides: plenty of sleep, fluids, moderation of sexual activity, and chicken soup s holy seven psychosomatic illnesses. By the 90 s

24 The classifications Tucson children s respiratory study Avon longitudinal study 3 or 5 categories of early childhood wheeze Transient early wheeze Prolonged early wheeze Intermediate onset wheeze Late onset wheeze Persistent wheeze

25 What we know Never wheeze Early wheeze Transient infant wheeze Boys, prematurity, smoking during pregnancy, family history of asthma or allergy, previous pregnancies and daycare attendance Persistent wheeze Boys, a family history of asthma or allergy, not breastfeeding for at least 3 months

26 Different phenotypes?

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28 Back to Bethany A appearance (airway) Mental status, muscle tone, body position B breathing Visible movement, (chest/abdo), effort normal/increased Accessory muscle /recession Count the RR C colour (circulation)?tachycardia

29 Age Normal respiratory rates Normal pulse rate Systolic BP Newborns and infants Up to 6 months old breaths/min >60 Infants 6 to 12 months old breaths/min >60 Toddlers and children 1 to 5 years old breaths/min >70 Children 6 to 12 years breaths/min >80 Refs: health.msn.com and health.ny.gov/professional.ems.education

30 Bronchiolitis Viruses - Respiratory Syncytial Virus 15% of infants will present for care < 1 year 1 2% requiring hospitalization Incidence similar in the United States, United Kingdom, Greece, Portugal, Saudi Arabia,

31 Treatment Salbutamol Consider a trial of salbutamol if: child is > 6 months old history of atopy previous history of wheeze. Assessment includes clinical examination, pulse rate, oximetry and Bronchiolitis Assessment Tool (BAT). If a trial is indicated then give six puffs of 100 mcg salbutamol via the spacer (one puff at a time through the spacer). Assess whether the child has improved 20 minutes after spacer given. Redipred There is no evidence regarding efficacy and benefit of using Redipred for management of bronchiolitis.

32 Send in < 1 RR > 60 HR > 140 From clinical pathway ADHB

33 Life is fired at us point blank range. We cannot say Wait until I have sorted things out Ortega y Gasset

34 Lost in translation? < 1 Bronchiolitis 1-2 Infant airways syndrome (viral) > 2 Asthma (? If seen more than twice? )

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36 Number of Admissions in Children 0-14 Years It s all in a name Wheeze R06 Asthma J46 Asthma J Hospital Admissions for Asthma and Wheeze in Children Aged 0 14 Years, New Zealand

37 Thank you