Published online August 1, 2007
PEDIATRICS Vol. 120 No. 2 August 2007, pp. 455 (doi:10.1542/10.1542/peds.2007-1450)
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LETTER TO THE EDITOR

The Importance of Disclaimers: Distinction Between Optimal Care and Standard of Care: In Reply

Richard N. Shiffman, MD, FAAP
Department of Pediatrics
Yale School of Medicine
New Haven, CT 06510

Allan S. Lieberthal, MD, FAAP
Chair
American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis
Kaiser Permanente
Panorama City, CA 91402

We appreciate the kind words from Slosberg and Smith regarding the disclaimer language that is appended to the American Academy of Pediatrics (AAP) evidence-based clinical practice guideline on bronchiolitis.1 It is important to note that the AAP's evidence-based practice guidelines are intended to improve the effectiveness of clinical care that is delivered to children by diminishing inappropriate practice variation.

We recognize that pediatricians practice in a litigious climate. Guideline authors are extremely careful in their wording of recommendations regarding clinical care, recognizing limitations in the scientific evidence and the potential for disagreements regarding interpretation and applicability of the evidence. Nonetheless, patients who seek our care often differ from those who are enrolled in clinical trials, and there may be legitimate reasons to deviate from published recommendations. The AAP has approached this problem by defining a taxonomy of strength of recommendations (including strong recommendations, recommendations, and options) and by classifying statements on the basis of quality of evidence and weighing anticipated benefits against risks, harms, and costs when recommendations are followed.2

Guidelines are used both as a "shield" for defendants and as a "sword" by plaintiffs. They have not been "treated as dispositive, but are considered as one piece of evidence among others that bear on liability determination."3 Rosoff4 noted that clinical practice guidelines are used not only in malpractice claims but also for coverage decisions made by health plans. They are presented as guidance for clinicians and are not intended to be benchmarks in the legal or reimbursement arena.

REFERENCES

  1. American Academy of Pediatrics, Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006;118 :1774 –1793[Abstract/Free Full Text]
  2. American Academy of Pediatrics, Steering Committee on Quality Improvement and Management. Classifying recommendations for clinical practice guidelines. Pediatrics. 2004;114 :874 –877[Abstract/Free Full Text]
  3. Samanta A, Mello MM, Foster C, Tingle J, Samanta J. The role of clinical guidelines in medical negligence litigation: a shift from the Bolam standard? Med Law Rev. 2006;14 :321 –366[Free Full Text]
  4. Rosoff AJ. Evidence-based medicine and the law: the courts confront clinical practice guidelines. J Health Polit Policy Law. 2001;26 :327 –68[Abstract]
PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics

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