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

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

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

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

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

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

The sharp and pointy end of child health

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 => ED

• Discharge code – “Bronchiolitis “

Ambulatory Sensitive Hospitalisations in Children Aged

0–4 Years by Primary Diagnosis,

New Zealand 2006–2010

Primary Diagnosis

Number: Total

2006–2010

Number: Annual Average

Rate per 1,000

Percent (%)

New Zealand Ambulatory Sensitive Hospitalisations 0–4 Years

Emergency Department Cases Included

Gastroenteritis 21,329 4,265.8 14.8 23.0

Acute Upper Respiratory Tract Infections 15,595 3,119.0 10.8 16.8

Asthma 15,511 3,102.2 10.8 16.7

Dental Conditions 13,261 2,652.2 9.21 14.3

Bacterial/Non-Viral Pneumonia 10,898 2,179.6 7.57 11.8

Skin Infections 7,743 1,548.6 5.38 8.35

Otitis Media 2,804 560.8 1.95 3.02

Dermatitis and Eczema 2,215 443.0 1.54 2.39

Constipation 1,523 304.6 1.06 1.64

Gastro-Oesophageal Reflux 1,353 270.6 0.94 1.46

Bronchiectasis 204 40.8 0.14 0.22

Nutritional Disorders 170 34.0 0.12 0.18

VPD ≥ 6 Months: DTP, Polio, HepB 77 15.4 0.05 0.08

VPD ≥ 16 Months: MMR 26 5.2 0.02 0.03

Rheumatic Fever/Heart Disease 19 3.8 0.01 0.02

New Zealand Total 92,728 18,545.6 64.4 100.0

Who Cares ?

• 2 – 3 fold variation

The project • Prevalence of

Childhood morbidity patterns ?

• Interrogate PMS systems

• Prevalence and utilisation data

Method

• 36 Primary Care practices and After Hours / ED data

• Networks of 2 PHOs

• All Doctor consultations children <18

• 1 Jan 2008 – 31 Dec 2013

• N= 754,242

• Coded data and free text from patient notes

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

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

1. Creating respiratory condition categories

Respiratory conditions

What is already coded?

Up to 24% of the 553 respiratory consultations identified by expert clinicians

2. A gold standard

• 12 practices

• (10 GP 2 AHC)

• 1193 notes reviewed separately by 2 GPs

• Diagnoses classified and defined

What is seen – 1200 consultations

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

Interim Test set – different set of random selected notes 1200

• Second set of clinician classification

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.

• 1930’s holy seven psychosomatic illnesses.

• By the 90’s …………

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

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

Different phenotypes?

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

Age Normal respiratory rates

Normal pulse rate

Systolic BP

Newborns and infants

Up to 6 months old 30-60 breaths/min 100 – 160 >60

Infants 6 to 12 months old 24-30 breaths/min 100 - 160 >60

Toddlers and children

1 to 5 years old 20-30 breaths/min 90 - 150 >70

Children 6 to 12 years 12-20 breaths/min 70 – 120 >80

Refs: health.msn.com and health.ny.gov/professional.ems.education

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,

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.

Send in

• < 1

• RR > 60

• HR > 140

From clinical pathway ADHB

Life is fired at us point blank range. We cannot say “

Wait until I have sorted things out” Ortega y Gasset

Lost in translation ?

• < 1 Bronchiolitis

• 1-2 Infant airways syndrome (viral)

• > 2 Asthma ( ? If seen more than twice? )

Hospital Admissions for Asthma and Wheeze in Children Aged 0–14

Years, New Zealand 2000–2012

0

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2000

3000

4000

5000

6000

7000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

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Asthma J46

Asthma J45

It’s all in a name

Thank you