Neonatal hyperbilirubinemia: Assessing variation in knowledge and practice

PLOS ONE RESEARCH ARTICLE Neonatal hyperbilirubinemia: Assessing variation in knowledge and practice Danielle Owerko ID1☯, Kelsey Ryan ID2☯, Erwin Cabacungan2☯, Ke Yan3☯, Kris Saudek ID2☯* 1 Division of Hospital Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America, 2 Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America, 3 Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America ☯ These authors contributed equally to this work. * a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 OPEN ACCESS Citation: Owerko D, Ryan K, Cabacungan E, Yan K, Saudek K (2023) Neonatal hyperbilirubinemia: Assessing variation in knowledge and practice. PLoS ONE 18(2): e0282413. https://doi.org/ 10.1371/journal.pone.0282413 Editor: Atnafu Mekonnen Tekleab, St Paul’s Hospital Millennium Medical College, ETHIOPIA Received: November 29, 2022 Accepted: February 14, 2023 Published: February 28, 2023 Copyright: © 2023 Owerko et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper and its Supporting Information file. Funding: The authors received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. Abstract Introduction Neonatal hyperbilirubinemia (NH) is commonly diagnosed and managed by pediatricians in various clinical settings. The 2004 American Academy of Pediatrics (AAP) Clinical Practice Guideline on NH is widely cited, but literature examining variation across pediatric specialties is limited. This study aimed to assess baseline knowledge and practice habits regarding NH among pediatric providers across various specialties immediately prior to the release of the 2022 NH clinical practice guideline. Methods A non-probability, convenience, self-selected sampling survey was electronically distributed to 311 subjects across five specialties within one pediatric healthcare institution. The survey included eight multiple choice knowledge-based questions with confidence assessments and five management-based questions assessing respondent agreement on a 5-point scale. To compare groups, the Kruskal-Wallis and Mann-Whitney tests were used for continuous variables, and the chi-square and Fisher’s exact tests were used for categorical variables. Results The overall survey response rate is 46%. There were significant differences between specialties’ knowledge regarding NH (p<0.05). There were also significant differences between specialties’ confidence ratings, independent of choosing the correct response (p<0.05). For select management-based questions, there were also significant differences between specialties (p<0.05). A majority of respondents (56%) indicated phototherapy treatment thresholds should remain the same in updated management guidelines. PLOS ONE | https://doi.org/10.1371/journal.pone.0282413 February 28, 2023 1/9 PLOS ONE Neonatal hyperbilirubinemia Conclusions Significant variations in knowledge and management of NH were identified among pediatric specialties. This suggests dissemination of new guidelines must be cognizant of different constraints impacting knowledge and practice across specialties. Introduction Pediatricians commonly diagnose and manage neonatal hyperbilirubinemia (NH) in various healthcare settings [1–6]. Defined as an elevated total serum bilirubin (TSB) level, hyperbilirubinemia clinically manifests as jaundice and affects a majority of all newborn infants [4, 5]. The most severe risk of untreated hyperbilirubinemia is kernicterus, characterized by longterm neurologic damage from bilirubin deposits in the brain [5, 6]. In 2004, with an update in 2009, the American Academy of Pediatrics (AAP) published a Clinical Practice Guideline (CPG) entitled Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation [1]. This CPG has since served as the main evidence-based set of recommendations guiding management of NH across clinical environments. At the time this survey was conducted, our institution used the 2009 recommendations, including when and where to initiate phototherapy, as the basis for our local practice pathway that is referenced when caring for infants in the newborn nursery, acute care floor, neonatal intensive care unit (NICU), emergency department (ED), and outpatient primary care practices. In August 2022, the AAP published a revised CPG which updated the common risk factors for severe NH and adjusted phototherapy thresholds across all gestational age categories based on extensive review of new evidence [2, 3]. It is anticipated that providers will promptly begin using the new guidelines to inform their clinical decision-making regarding NH. A review of existing literature identified studies that examined providers’ knowledge and practice habits within individual specialties [7, 8], or amongst a select few primary care specialties [9], but none have studied where variations exist between all pediatric specialties that most commonly manage the care of jaundiced infants. Therefore, the primary aim of this study was to assess baseline knowledge and current clinical practice habits amongst all specialties that manage NH within a single healthcare institution. Methods A non-probability, convenience, self-selected sampling survey was created by the authors using Qualtrics [10]. A comprehensive literature review regarding NH was conducted and used to guide question development. The survey consisted of two demographic questions and eight multiple choice knowledge-based questions with corresponding confidence assessments for select questions (sliding scale 0–100). We also assessed respondent agreement with five NH management scenarios (“practice habits”) on a 5-point scale. Full text of the survey, with citations and correct answers highlighted, can be found in S1 File. The preliminary survey was shared with a group of subject matter experts and learners who provided feedback regarding question content and time to complete the survey. Once finalized, the survey was electronically disseminated to 311 physicians at our free-standing tertiary care children’s hospital in the Midwest United States. Invited respondents were pediatric hospitalists, neonatologists, pediatric emergency medicine (PEM) physicians, pediatric residents, and outpatient primary care pediatricians. The survey was first disseminated on October 11, PLOS ONE | https://doi.org/10.1371/journal.pone.0282413 February 28, 2023 2/9 PLOS ONE Neonatal hyperbilirubinemia 2021 and two reminder emails were subsequently sent b (...truncated)