Panel Paper: Professional Society Recommendations and Physician Behavior: Regression Discontinuity Evidence from the American Academy of Pediatrics Policy Statements

Friday, November 9, 2012 : 8:20 AM
International D (Sheraton Baltimore City Center Hotel)

*Names in bold indicate Presenter

Jeremy Craig Green1, Clara Filice2, Marjorie Rosenthal3 and Joseph Ross3, (1)Yale School of Public Health, (2)American Academy of Pediatrics, (3)Yale School of Medicine

Policy Background

Over several decades, American Academy of Pediatrics (AAP) clinical guidance regarding use of routine urinalysis to detect chronic kidney disease in asymptomatic children has evolved.  In both 1977 and 1992, the AAP recommended routine urine testing at four times during childhood.  Revised guidance in 2000 limited testing to only two populations, five-year-olds and sexually active adolescents.    In light of accumulating evidence that it lacked clear benefit relative to its associated costs and risks, in 2007 the AAP recommended discontinuing use of routine urinalysis altogether.  

Study Objective

Although many factors have been shown to contribute to guideline adherence, previous work evaluating the impact of clinical care recommendations on pediatric preventive care practices has been limited by lack of comparison groups and self-reports of physician behavior.   Using data from the National Ambulatory Medical Care Survey (NAMCS), a nationally representative survey evaluating use and provision of ambulatory medical care services in the United States, the objective of this study was to evaluate the impact of the 2007 AAP policy statement discontinuing use of routine urinalyses in children. 

Research Design

We used a regression discontinuity design within a nonlinear difference-in-differences framework (e.g. studying data from time periods before and after the AAP policy statement) to evaluate the effects of two discontinuities in AAP policy statements – a “fuzzy” discontinuity to examine the effects of AAP’s recommendation to discontinue routine urinalysis for individuals under age 18 and, within the same model, a “sharp” discontinuity to examine the effects of AAP’s recommendation to discontinue the recommendation to perform routine urinalysis for 5 year olds.  We interacted the estimated policy effects at each age of interest with an indicator for community health centers or private practices to examine differential effects of the AAP policy statements by physician practice setting.

Preliminary Results

AAP’s 2007 recommendation to discontinue use of screening urinalysis for individuals under the age of 18 was associated with a 4 percentage point decrease in the prevalence of urinalysis for preventive care visits by individuals under the age of 18 to pediatricians and generalists – a decrease in routine urine testing of 23 percent.   Effects were larger for community health centers, where routine urinalysis decreased by approximately 11 percentage points, or 55 percent.  For private practices, the decrease was 3 percentage points; a decrease from baseline of 15 percent.  The changes to age 5 recommendations were also more effective for community health centers than for private practices.   The age profile of routine urinalysis peaked at age 5 before the recommendation to discontinue routine testing at this age.   Following the recommendation, the age profile continued to peak at age 5 for private practices, but no longer peaked for community health centers.   The results of this analysis inform clinicians, guidance developers, and policymakers about current screening urinalysis practices and impact of a change in clinical recommendations on preventive care practices.