Massie J, Efron D, Cerritelli B, et al. Arch Dis Child. 2004;89:660–664
Purpose of the Study.
To evaluate a systemic and coordinated approach to the development and implementation of evidence-based asthma guidelines for a pediatric hospital.
This was a comparative study conducted at the Royal Children’s Hospital in Melbourne, Australia. There were 3 cohorts of children evaluated between the ages of 2 and 18 years who presented with acute asthma to the emergency department. Cohort 1 presented before the development of asthma guidelines, cohort 2 was recruited to assess the effectiveness of guideline implementation, and cohort 3 was recruited 1 year later to assess the sustainability of guideline changes.
The Royal Children’s Hospital best-practice guidelines for the care of asthma were established after careful review of established national/international guidelines and consideration of evidence-based reviews in the literature. The guidelines also took into consideration recommendations from Improving Child and Adolescent Asthma Management members. There was a detailed launch of the guidelines in the institution, with a major focus on implementation of the guideline recommendations through a variety of vectors. The primary outcome measures of this study were rates of reattendance and readmission to the hospital, a change in asthma morbidity, and quality of life.
There were 374 children in cohort 1, 363 in cohort 2, and 377 in cohort 3. There was no difference in baseline characteristics between the cohorts (age, gender, asthma severity). There was no statistically significant difference in the proportion of patients who revisited the emergency department or were admitted to the hospital between the 3 groups within 6 months of the initial presentation (21–27% for revisits to the emergency department and 11% rehospitalization). There also were no differences in measures of morbidity between the cohorts across 3 domains (interval symptoms, exercise compromise, and bronchodilator usage) or in parent or child quality-of-life scores between the groups. However, there was a significant increase in those who were given asthma-management plans with the implementation of the practice guidelines.
The implementation of evidence-based guidelines made no difference in readmission to the hospital, return visits to the emergency department, asthma morbidity, or quality of life but did increase the provision of asthma-management plans. The authors concluded that future efforts to improve asthma management should target specific components of asthma care.
Certainly the results of this study are disappointing, especially for those of us who develop, implement, advocate, and teach guidelines. Were the guidelines at fault? Were the guidelines implemented properly? Were they carried through for both sides of the illness, and if so, for how long? It was not clear what went on after the first encounter. Was there appropriate follow-up with guideline-savvy primary caretakers who were able to emphasize the guidelines? My guess is that perhaps more emphasis and more “implementation” is needed more frequently at the patient/caretaker level, and I would not give up on guidelines just yet.