“Guidelines” for Guideline Implementation
Article Outline
The growing number of articles in the pediatric literature focused on evidence-based or consensus-driven clinical practice guidelines has taken on increased importance because of concern for quality of care relative to rising costs. Most studies have come to 2 unmistakable conclusions. The first is that, when properly implemented, guidelines have the potential to reduce the well-recognized wide variability in delivered care affecting positive outcomes.1 The second is that guidelines are often ignored by practitioners, leading to no measurable improvements in care. Even when used, they are not used consistently.2
See related articles, pp 786 and pp 789
This issue of The Journal includes examples of both. The article by Conway and Keren3 again demonstrates that institutions systematically using clinical practice guidelines reduced variability of care leading to improved outcomes. Although the reliability of the systems is not reported (what percentage of patients at each institution received evidence-based care), the institutions that stated they used evidence-based guidelines had shorter lengths of stay and less variation in care in the management of urinary tract infections. The second article, by Weinberger,4 is a reminder that guidelines known to improve care for asthma for almost 2 decades remain unused or used inconsistently by most practicing pediatricians, resulting in continued variation in care and little improvement in measurable outcomes. The question that remains unanswered is: “How do we get physicians to use the best available evidence to deliver care and how do we get all of them to do it all of the time?” Answer that question and there will be less unexplained variation both locally and nationally, a more rapid implementation and spread of what works, and improved outcomes. There are some tantalizing examples that suggest how we might do this in pediatrics.
Both articles offer partial solutions. Weinberger4 suggests that exposure to “an asthma care program with a demonstrable track record for successful outcomes” during training would pay benefits when pediatricians enter practice. It is hoped that residents would learn not only the best medical care but also how to improve care and to design and organize care delivery for chronic problems. He suggests that general pediatricians can manage successful asthma programs if they are designed properly, especially when done in conjunction with pediatric asthma subspecialists.5 Until this model is more widely implemented, Weinberger proposes that high-risk patients receive care in subspecialty-run clinics. That solution obviously comes with all the workforce and geographic barriers known to exist for most pediatric subspecialties. Conway and Keren3 suggest that 1 of first steps in improving quality is measuring performance at the local level and comparing that performance with known national benchmarks. Both solutions have merit and are necessary but not sufficient strategies to ensure the implementation and testing of guidelines to systematically improve care.
Guidelines have not been implemented by most practicing pediatricians because they cannot effectively do so. Most pediatricians have had little training in basic quality improvement techniques or concepts of reliability science.6, 7 They have not been taught how to measure what they do, most have not set goals or aims for improvement, many know little about change packages or the utility of Plan-Do-Study-Act cycles in effecting change, and most have no way of knowing whether adhering to guidelines is actually benefiting their patients. Many guidelines are complex, and it is often difficult to know which of the many recommendations are the most likely to lead to the greatest improvement. Most practices are not designed to collect real-time data on processes and outcomes, to function optimally as teams and to effectively involve patients in care. Rarely do practices coordinate care with other practices, share performance data, and learn rapidly from each other. Without spreading the use of these basic tools and creating the proper infrastructure to support practices, developing more guidelines and comparative measurement of performance will continue to produce disappointing results. Maybe it is time to slow the development of new measures and guidelines and direct efforts at giving pediatricians the skills and support to imbed existing guidelines in their daily practice.
Weinberger's suggestion of exposure to guideline implementation during residency though a clinic with demonstrable outcomes is an excellent idea that should be expanded. The best way to learn (and to teach) how to deliver quality care is to participate in the actual delivery of that care. Residents are currently required to master the competencies of systems-based practice and practice-based learning and improvement to complete training. This should be embedded in all areas of training and applied to all areas of practice not just limited to asthma. A good place to start would be participation in a long-term care program that demonstrates successful outcomes and that teaches, formally and by example, the principles of quality improvement, teamwork, and effective practice design. This would be an invaluable experience for both residents and faculty. For those in practice, the same requirements are found in the new Maintenance of Certification programs of all American Board of Medical Specialists specialty boards. Continued certification in a specialty will depend on being able to demonstrate improvement of care at the practice level.
There is growing evidence that guidelines can be incorporated into daily practice reliably and uniformly both locally and nationally. Using proven and simple quality improvement techniques, collaborative efforts by practicing pediatricians to deliver perfect asthma care have dramatically reduced both hospital admissions and emergency department visits (with appropriate subspecialty referral for complex patients).8 This local effort has served as model for at least 2 national efforts to spread effective asthma care. Hospitals have also benefited by collaborative efforts to reduce blood stream infections in pediatric intensive care units with marked reduction in infection rates, mortality and cost of care. There are now 62 pediatric intensive care units working together in this national collaborative.9 Development of improvement goals, baseline measurements of performance, interdisciplinary patient-centered teams implementing change directed at reaching those goals using the best evidence available, and remeasurement to assess the outcome of a change can and do make a difference. Open sharing of data across practices and systems to learn together what works increases the spread of best practices. Unless these elements become recognized as a “guideline” for effective care, measures- and evidence-based guidelines alone will continue to be ineffective in reducing the variability of care and improvements will not occur.
References
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- . The quality of ambulatory care delivered to children in the United States. N Engl J Med. 2007;357:1515–1523
- . Factors associated with variability in outcomes for children hospitalized with urinary tract infection. J Pediatr. 2009;154:789–795
- . Seventeen years of asthma guidelines: why hasn't the outcome improved in children?. J Pediatr. 2009;154:786–788
- . Asthma guideline use by pediatricians in private practices and asthma morbidity. Pediatrics. 2006;118:1880–1887
- . Reliability of the health care delivery system (J). Pediatr. 2005;146:581–582
- . Measure, learn, and improve: physicians' involvement in quality improvement. Health Aff. 2005;24:843–853
- . Pay for performance alone cannot drive quality. Arch Pediatr Adolesc Med. 2007;161:650–655
- . http://www.childrenshospitals.net/AM/Template.cfm?Section=Blood_Stream_Infections_Project
PII: S0022-3476(09)00214-5
doi:10.1016/j.jpeds.2009.02.055
© 2009 Mosby, Inc. All rights reserved.
Refers to article:
- Seventeen Years of Asthma Guidelines: Why Hasn't the Outcome Improved for Children?
- Factors Associated with Variability in Outcomes for Children Hospitalized with Urinary Tract Infection , 26 March 2009
