Assessment of adherence level for neonatal hyperbilirubinemia management by various physicians in ‎Iraq: a multi-clinic study

Introduction

Hyperbilirubinemia (HBR) is one of the commonest causes of neonatal readmission to hospital¹, it requires urgent medical attention with rapid and prompt management to reduce bilirubin to prevent severe complications, such as kernicterus².

Despite the development of several guidelines (including the American Academy of Pediatrics (AAP) in 2004) to optimize the management of HBR, still the rate of inappropriate and insufficient therapy is rising³, and consequently, the rate of morbidity will increase⁴. These facts raise concerns about knowledge translation from and physician awareness of available guidelines in the literature and how much they use these in their daily practice⁵.

Some surveys indicate that neonatologists are more aggressive than office-based general pediatricians in their treatment of neonatal jaundice in infants⁶. While others show considerable variation in management depending on the specialty of the physician, with pediatricians being shown to have both exceptionally good awareness and adherence to guidelines. Thus, it is important to enhance knowledge translation to physicians, thereby increasing adherence to these guidelines, especially in physicians other than pediatricians⁵.

Approximately 66% of pediatricians reported an awareness to neonatal hyperbilirubinemia clinical practice guidelines published in 1994⁷. However, Atkinson et al showed that only 54% of the pediatricians initiated treatment in accordance with recommended parameters⁸. This study aimed to assess the level of adherence of various physicians to different guidelines of management of neonatal hyperbilirubinemia in a multi-clinic survey in Iraq.

Methods

Results

In total, 130 physicians participated in this questionnaire-based study: 21 (16.15%) were EPs, 73 (56.15%) GPs, and 36 (27.67%) PDs.

PDs had a significantly higher age compared to both ERs and GPs. The majority of all physician groups worked at level I NICU (66.7%, 72.6%, 50.0%; respectively); notably more PDs worked at level II and III NICU compared to other groups. Both GPs and PDs had a longer duration of practice compared to an EPs, and additionally, PDs saw the most neonates per month compared to EPs and GPs (Table 1).

PDs had significantly longer discharge times of neonates compared to EPs and GPs. In addition, 91.7% of PDs always tested the neonate for bilirubin levels before discharge, while only 5.5% of GPs and 0% of EPs did so. Regarding follow-up visits, 16.7%, 4.8% and 45.2% of PDs, EPs and GPs, respectively, scheduled a follow-up between 49–72 hours; 47.6% and 38.1% of EPs scheduled a follow-up at ≤24 hours and 25–48 hours, respectively (Table 2).

Table 3 illustrates the assessment of physician knowledge toward assessment of HBR. It shows that recognizing visual signs and jaundice within 24 hours of birth was performed to a higher extent by PDs compared with EPs and GPs.

In total, 91.7% of PDs gave the correct answer for the case scenario, followed by GPs (58.9%) and EPs (38.1%) (Table 4).

Discussion

In this survey, there was obvious variation in the adherence of various groups of physicians to guidelines for treating neonates with HRB. The results showed that 74% of GPs and 61.9% of EPs did not use any guidelines for the management and identification of neonatal HBR; PDs on the other hand did use guidelines. These findings were higher than reported in other countries. Sampurna et al, in a study conducted in Indonesia that involved 291 midwives, 206 GPs, and 154 PDs, reported that 23% of GPs and 29% of midwives were unaware of the presence of guidelines for identification and management of neonatal HBR¹⁴. In a study by Mateo et al, which involved 321 Canadian physicians, they reported that guidelines were used by 41% of family physicians, 75% of PDs, and 69% of midwives, which is partially in agreement with our findings⁵.

Early identification is the cornerstone of any guideline created to manage HBR^3,10,15. Monitoring of the neonate with HBR is achieved via measurement of bilirubin especially in the first 3 days of life¹⁶, with subsequent follow-up every 24-48 hours till oral feeding is assured¹⁶. In the present study, before discharge monitoring of bilirubin was being performed by only 5.5% of GPs, 0% of EPs and 91.7% of PDs. In addition, 90.5% of EPs and 94.5% of GPs reported the use of pre-discharge bilirubin testing only if the infant looked jaundiced. This finding is higher than that reported by a previous Iraqi study by Hameed and Abdul Razak¹⁷, who reported that 56% of PDs did not consider post-discharge total serum bilirubin monitoring. In the Canadian study by Mateo et al, 42% of family physicians and 22% of midwives compared with 63% of PDs, reported bilirubin measurement before discharge, which is lower than reported by the current study⁵. In the Indonesian study, 12% of GPs and 8% of PDs reported always performing pre-discharge bilirubin measurement, while 54% of GPs and 65% of PDs reported the use of pre-discharge bilirubin measurement only if jaundice was present, which is partially in agreement with our findings¹⁴. In addition, in a study by Petrova et al, which involved 356 PDs in the USA, they reported that 87.4% of all physicians used TSB testing with clinical jaundice before discharge, while 57.7% of them only used TSB testing in clinical jaundice post-discharge, which in agreement with our findings¹⁸.

In the present study, all PDs considered jaundice in less than 24 hours of life as an indicator of severe HBR, compared with 81.0% of EPs and 67.1% of GPs. This is in agreement with the study by Hameed and Abdul Razak that showed that 76% of PDs strongly agreed that neonates presenting with jaundice in the first 24 hours as a predictor of severe HBR¹⁷. Petrova et al reported similar findings: 77% of physicians considered that jaundice presenting in the first 24 hours was a marker for severe HBR¹⁸. Several studies in the literature indicate the importance of early first-day measurement of bilirubin levels since elevated levels are correlated strongly with later severe complications^19–21. There was good knowledge of this by physicians in this study.

In the present study, PDs relied less on visual assessment of jaundice (5.6%), jaundice in stool and fever (0%), and jaundice at 14 days when the baby is active and growing (0%), compared to EDs and GPs. The Hameed and Abdul Razak study reported few PDs (10%) agreed that jaundice noticed at discharge is a risk factor for severe HBR¹⁷, which was in agreement with our findings. Around 61% of primary health care provider assessed the severity of neonatal jaundice by visual cephalocaudal evaluation inspecting the skin or sclera, which is rapid and cost-free, but it is not sufficiently accurate, especially when applied to newborns with dark skin²², which disagrees with our findings.

In the present study, the majority of PDs gives the correct answer (laboratory tests bilirubin and blood group) to the case scenario (91.7%); however lower correct answer rates were achieved by GPs (58.9%) and EPs (38.1%) (p-value = 0.002). In the Mateo et al study, the response to a case scenario similar to ours showed similar results to our findings, while in the Sampurna et al study, the response to a similar case scenario showed a lower correct answer rate with 54% of PDs, 57% of GPs, and 44% of midwives providing the correct answer¹⁴.

Hospital affiliation of health care providers is one of the strongest predictors of adherence to practice guidelines⁶, which is one of the possible explanations of the high rate of good knowledge about the management of neonatal HBR shown in the present study. The variability of the use of guidelines for the management of HBR in this study was similar to others^8,23. Barriers to adherence include low awareness, no agreement, and inertia of previous practices²⁴.

Conclusions

GPs and EPs in this study, performed in Iraqi hospitals, showed lower adherence levels for the management of neonatal jaundice than PDs, who exhibit excellent adherence to current guidelines (WHO, AAP, and NICE guidelines), especially AAP guidelines. We recommend starting an education program directed toward the enhancement of knowledge for EPs and GPs for the management of neonatal jaundice.

Data availability

Zenodo: Adherence Level for Neonatal Hyperbilirubinemia, https://doi.org/10.5281/zenodo.3745611²⁵.