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ELECTRONIC ARTICLE: David W. Johnson, Carol Adair, Rollin Brant, Joanne Holmwood, and Ian Mitchell Differences in Admission Rates of Children With Bronchiolitis by Pediatric and General Emergency Departments Pediatrics 2002; 110: e49 [Abstract] [Full text] [PDF]

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admission ratesd:expertise and/or guidelines?

Alfredo Guarino, Giulio De Marco, Sebastiano Mangani, Antonio Correra, Alessandro de Franciscis   (28 November 2002)

Re: admission rates:expertise and/or guidelines?

David W. Johnson   (12 December 2002)

admission ratesd:expertise and/or guidelines? 28 November 2002
Alfredo Guarino, MD, Associate Professor of Pediatrics University Federico II, Naples, Italy, Giulio De Marco, Sebastiano Mangani, Antonio Correra, Alessandro de Franciscis Send letter to journal: Re: admission ratesd:expertise and/or guidelines? alfguari{at}unina.it Alfredo Guarino, et al.	Johnson and coworkers suggest that physicians working in pediatric emergency departments manage children with bronchiolitis in a more effective way than those working in general hospitals, as suggested by lower admission rates. They suggest that greater experience and expertise by pediatricians yield overall cost efficiencies for the health care system. In their retrospective study, however, the reasons for admissions were not stated. On the other hand, widely accepted, evidence-based guidelines for admissions are not available, to assist physicians in the emergency room in deciding admission of children with acute respiratory disease. The Italian Minister of Health has recently released evidence-based guidelines for the management of flu-like syndrome, that include specific indications for hospital admissions of children (available at www.pnlg.it). Risk factors of poor outcome, including clinical parameters or underlying conditions, such as congenital hart disease, were included as mandatory for admission. Specific indications for considering admission were also provided, but a strong recommendation against admission was included for mild to moderate conditions. In a survey performed by independent observers in an emergency room of a pediatric hospital in Naples, the admission of children with flu- like was closely monitored and reasons for admission were compared with those recommended by the national guidelines, just prior to their implementation. Out of 854 children seen in 20 sample days during 2001 influenza season, 318 (37%) presented with flu-like syndrome, 86 (27%)of whom were admitted. The main reasons for admission were mild to moderate disease (34%) and bronchiolitis (14%). Overall as many as 33% of children admitted with flu-like, did not match any of the criteria included in the guidelines for considering or recommending hospitalization. We believe that although experience and expertise are important determinants of efficiency, evidence-based guidelines may be effective in reducing the rate of unappropriate admissions of children with acute respiratory disease.
Re: admission rates:expertise and/or guidelines? 12 December 2002
David W. Johnson, Pediatric Emergency Physician University of Calgary Send letter to journal: Re: Re: admission rates:expertise and/or guidelines? david.johnson{at}calgaryhealthregion.ca David W. Johnson	I agree with Guarino that clinical practice guidelines have the potential to change practice patterns. However, a substantial body of evidence has been published which demonstrates that development and simple dissemination of guidelines does not guarantee physician practice patterns will change.[1, 2] First of all, guidelines must be rigorously developed and evidence- based.[3] Second and most important, guidelines must be actively implemented.[1, 2] Those strategies that have been shown to be consistently effective at changing behavior include interactive educational sessions, academic detailing, and reminder systems.[1, 2] Consequently changing physician behavior is not easy nor inexpensive. More specifically, Perlstein et. al have already demonstrated that the rigorous development and active implementation of a guideline for bronchiolitis can substantially reduce the rate of hospital admission and the average length of stay in a Children's Hospital, without any documented adverse events.[4] Their finding does not invalidate our results - that in our community, emergency physicians' working in a children's ED admit relatively fewer children with bronchiolitis than those physicians working in a general ED. The unanswered question is - if we developed and implemented a clinical guideline in both the Children's hospital and the general hospitals - would these institutional practice differences lessen, remain, or increase. 1. Bero, L., et al., Getting research findings into practice: Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research fundings. BMJ, 1998. 317: p. 465-8. 2. Grimshaw, J., et al., Changing provider behavior: an overview of systematic reviews of interventions. Med Care, 2001. 39(8 (Suppl 2)): p. II-2-II-45. 3. Grimshaw, J., M. Eccles, and I. Russell, Developing clinically valid practice guidelines. J Eval Clin Pract, 1995. 1(1): p. 37-48. 4. Perlstein, P.H., et al., Evaluation of an evidence-based guideline for bronchiolitis. Pediatrics, 1999. 104(6): p. 1334-1341.