If a Guideline Falls in The Woods, and No One Hears It

Two recent articles highlight how ineffective guidelines can be:

  • J Pediatr 2014; 165: 570-6.
  • J Pediatr 2014; 165: 585-91.

In the first retrospective multicenter study, the authors note that hospitals with institutional clinical practice guidelines (CPGs) for bronchiolitis did not have significant reductions in the use of tests and treatments (eg. complete blood count, chest X-ray, bronchodilator use, steroid and antibiotic use).  However, two factors, time that CPG had been in place and ready access to an online written document were associated with a reduction in tests and corticosteroids.

In the second study, a retrospective cohort study of 17,299 cases of uncomplicated pneumonia at 125 hospitals, antibiotic choices rarely coincided with recommended guidelines.  “Ampicillin or penicillin G is strongly recommended for first-line management of uncomplicated pediatric CAP [community acquired pneumonia] in the inpatient setting barring substantial high level penicillin resistance of Streptococcus pneumoniae in the community.” Yet, in this study, about 75% received a third-generation cephalosporin and 5-10% received monotherapy with a macrolide.  The former is generally unnecessary and not advantageous, whereas the latter has a lower efficacy. Less than 1% received a recommended choice.

Bottomline: These studies have obvious implications well beyond bronchiolitis and pneumonia. Experts can agree on plethora of guidelines but they are almost meaningless without efforts to get clinicians to use them.

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