What We Do and Why We Do It...or What We Don't Do and Why Not
December 2005


The end of the year provides an excellent opportunity (but not always the time!) to reflect on the preceding year. Here is a brief review of a few publications that caught our eye in the past year.

1) Cloutier MM. Hall CB. Wakefield DB. Bailit H. Use of asthma guidelines by primary care providers to reduce hospitalizations and emergency department visits in poor, minority, urban children. Journal of Pediatrics. 146(5):591-7, 2005 May.

The authors note that anti-inflammatory drugs for chronic asthma are under-prescribed. This five-year study evaluated the effect of an asthma management program on over 3,400 children with asthma and their primary care providers (PCPs). The ‘intervention’ included diagnosing asthma, determining its severity, prescribing appropriate therapy and providing families with a written asthma action plan. The results included a marked increase in PCPs adherence to guidelines for use of inhaled anti-inflammatory therapy for asthma (from 38% to 96%). Children enrolled in the program had a 35% decrease in asthma hospitalizations and a 27% decrease in Emergency Room (E.R.) visits for asthma. Children with asthma who were not enrolled in the program did not experience any decrease in admissions or E. R. visits.

While there is certainly some resistance among families to inhaled steroid use, there is ample evidence that it is safe and effective in helping to optimize asthma care. As PCPs, we need to continue doing a better job of assessing asthma severity (e.g. frequency of bronchodilator use) and recommending inhaled anti-inflammatory medications as indicated. (e.g. for several weeks after hospitalization or E.R. visit for asthma or when a child uses a bronchodilator more than twice a week or more than twice a month at night.)

Information and printable asthma action plans for families and physicians can be found at Sutter’s Pediatric Web site: kids.sutterhealth.org

2) Sox CM. Christakis DA. Pediatricians’ screening urinalysis practices. Journal of Pediatrics. 147(3):362-5, 2005 Sep.

This survey of 1,500 pediatricians (with a 50% response rate) revealed that the vast majority of pediatricians surveyed did screening urinalyses on asymptomatic children at some point in childhood. Only about one-third of respondents felt this screening improved the overall health of children. About half of those surveyed are not screening at five years of age as recommended by the American Academy of Pediatrics (AAP).(1)

This study raises as many or more questions than it answers. At a minimum it suggests (as have other studies(2), that many pediatricians are either not familiar with or choose not to follow national recommendations/guidelines. The well documented under-utilization of anti-inflammatory therapy for asthma raises the same concern. However, it is important to note an important difference between these two studies. There is ample evidence to support use of anti-inflammatory therapy in asthma. As the study below points out, this is not the case for many of our routine well child visit practices.

3) Moyer VA. Butler M. Gaps in the evidence for well-child care: A challenge to our profession. Pediatrics. 114(6):1511-21, 2004 Dec.

About one-third of pediatric visits are for well child care. Schools, insurers and others mandate and monitor compliance with many preventive care guidelines. This study looked for evidence to support 42 different counseling, screening and prophylactic recommendations in well child care. Each of these recommendations is supported by at least two different national organizations. There is some evidence suggesting a benefit from counseling (e.g. injury prevention). As might be expected, the degree of benefit shown in various studies is relative to the intensity of counseling. There is virtually no evidence to support (or refute) the majority of recommendations for the broad range of screening practices (e.g. vision, urinalysis, lipid testing, etc). The authors note that the absence of evidence should not be taken to mean the interventions are ineffective. However, current recommendations exceed the capacity of the health care system and ongoing research is critical to future practice in this area.

4) Sand N. Silverstein M. Glascoe FP. Gupta VB. Tonniges TP. O’Connor KG. Pediatricians’ Reported Practices Regarding Developmental Screening: Do Guidelines Work? Do They Help? Pediatrics, Jul 2005; 116: 174 - 179.

Approximately 10-15% of children have developmental difficulties. Early intervention has proven to be of value for many conditions. Many families report that their child never received a developmental assessement.(3) The AAP recommends universal developmental screening and emphasizes the importance of standardized screening tools.(4) More than 600 practicing general pediatricians responded to the survey. Less than one-quarter of them use a standardized instrument to assess development. These pediatricians reported a higher percentage of their patients with developmental problems compared to physicians who do not use standardized screening. Inadequate time, staff and reimbursement were cited as obstacles to more thorough developmental screening. The authors express concern that in the current system of care, pediatricians may be missing opportunities to positively impact children with developmental differences.

5) Shaughnessy AF. Slawson DC. Easy ways to resist change in medicine. British Medical Journal 329(7480): December 18, 2004, 1473-1474.

This article references the 2000 article on alternatives to evidence-based medicine5 (vehemence, eminence, etc) and lists 10 techniques to help physicians resist change. These include: don’t pay attention, attack the data, question the applicability to your patients, pull rank and simply refuse...e.g. “I wouldn’t believe this information even if it were true.” The tongue-in-cheek article is a pointed reminder of the challenges we face in evaluating data and changing our practice habits to improve the health of the children we serve.

References

1. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. Recommendations for Preventive Pediatric Health Care. Pediatrics 2000; 105:645-646.

2. Christakis DA RF. Pediatricians awareness of and attitudes about four clinical practice guidelines. Pediatrics 1998; 101:825-830.

3. Halfon N, Regalado M, Sareen H, Inkelas M, Peck-Reuland, CH, Glascoe, FP, Olson, LM Assessing Development in the Pediatric Office. Pediatrics, Jun 2004; 113: 1926 - 1933.

4. American Academy of Pediatrics: Committee on Children With Disabilities: Developmental Surveillance and Screening of Infants and Young Children. Pediatrics, Jul 2001; 108: 192 - 195.

5. Bleck TP. Alternatives to Evidence Based Medicine. BMJ 2000; 321:239