Monday, June 29, 2015

National Guidelines for Pediatric Illness Management: They May Exist But Do We Ever Read Them, Let Alone Use Them?

By: Lewis First, MD, MS; Editor-in-Chief  

COD Newsroom
          In almost every issue of Pediatrics, we seem to be publishing a set of guidelines for diagnosing, treating, or preventing one pediatric illness or another—all of them as evidence-based as possible in the recommendations they make. Yet despite their import, creation or endorsement by a Section or Committee of the American Academy of Pediatrics (AAP), and despite the publicity they may get in AAP’s Pediatric News and often by the mass media itself, awareness of these guidelines remains less than optimal.  This week we share two studies reinforcing the benefits of using the guidelines as well as the variability and increased cost of care when such guidelines are not used.  The first of these studies by Williams et al. (doi: 10.1542/peds.2014-3047) focuses on 2011 national guidelines for narrow-spectrum antibiotic use in children hospitalized with community acquired pneumonia (CAP) at three children’s hospitals.  To no surprise, when a hospital aggressively promoted and targeted the evidence-based guidelines throughout the institution, the use of penicillin/ampicillin increased significantly and the use of a third generation cephalosporin declined.
Similarly a second study by Mahant et al. (doi: 10.1542/peds.2015-0127) looked at the 2011 guidelines for tonsillectomy perioperative care and then using a retrospective cohort of children in a national database, analyzed perioperative care processes and outcomes pre and post-publication of these guidelines (e.g. use of perioperative dexamethasone, non-use of antibiotics).  While the results suggest more dexamethasone use post guidelines and lower antibiotic usage, the changes are only a few percentage points despite their significance and there was no change in overall outcomes and complications except some increased revisits due to pain issues.  Both studies suggest guidelines will work to improve quality and reduce cost but only if you use them.   
Are you using guidelines to share your clinical management?  If so, which ones?  If not, why not?  Are you guidelined out? Does your EHR system trigger a guideline when you enter a diagnostic code to help direct your management?  We are eager to hear how important clinical guidelines are to you so hopefully these two articles and blog will guide you to a response either below this blog, with an e-letter on with a posting on our Facebook or Twitter websites.

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