The publication of Kramer and Shapiro's review and critique of the practice guideline of Baraff et al on the diagnosis and treatment of the febrile child provides an excellent opportunity to review the pros and cons of clinical guidelines and their role in the enhancement of patient care.1,2 The authors comment on the variable quality of the literature used to develop the guideline of Baraff et al and the failure of the guideline's developers to account for variation in methodologic quality when creating summary statistics for each of the guideline's parameters. It is true that the papers used in the analyses were of varying quality. It also true that there is no validatedmechanism for making such adjustments, and there is a only a fine line between adjusting for bias and adding one's own bias. For this reason, we chose not to attempt such adjustments. The literature in this area (and in virtually every other area of medicine) is imperfect and incomplete. We attempted to summarize what was there, fully recognizing that what is published may be a poor proxy for the truth, but is all that we have.
Given these imperfections in the literature and its synthesis, can there be any useful role for guidelines, or are they merely a means of dressing up a priori beliefs in a format that creates a patina of credibility? To answer this we must examine why two sets of authors take the same set of facts and reach opposite conclusions. First, this occurrence is testimony to the paucity of available evidence and the need for research. Second, without compelling evidence to guide beliefs, it is not surprising that the authors see reflections of their own beliefs in the thin pool of existing evidence: the infectious disease experts who predominate the article by Baraff et al emphasize their experience with the rare child who does poorly; Kramer and Shapiro emphasize primary care practitioners' experience with the hundreds of children who do well.
What is it that prohibits the two sets of authors from reconciling their beliefs? It does not appear to be different interpretations of the data, but rather different models of the problem. While most academic pediatric researchers have approached the febrile child as if there is only one opportunity to make the correct diagnosis and initiate treatment, the majority of community pediatricians operate under the belief that if the child gets sicker they will have a second opportunity to act. This opportunity is predicated on two assumptions: that the care giver will recognize that the child is sicker and activate the health care system and that the natural course of the untreated disease is such that there is sufficient time to treat a child whose condition has deteriorated before he experiences any important morbidity. There has been little formal research investigating these assumptions, yet it is differences in the estimation of these factors that likely explain differences in beliefs. A physician who believes that children who get sicker will return will likely choose a practice style that takes more chances but is less invasive, while a physician who believes that he will get only one pass at each child is more likely to use a test and treatment intensive approach.
Thus, in 1997, there is no single right answer to this important set of clinical questions. The guideline of Baraff et al offers an evidence-based approach designed to further decrease the likelihood of the already rare bad outcome. The approach of Kramer and Shapiro is reasonable and is more consistent with current community practice. There is insufficient evidence to prove that it is more dangerous or less effective than the approach of Baraff et al.
Does the existence of two credible, partially contradictory approaches prove that guidelines are a sham? I think not. The publication of the guideline by Baraff et al in this journal stimulated a dialogue that highlights controversies in the field and focuses discussion on the critical issues. It elevates the level of discourse from sweeping global judgments (“all children with fever without source need a full septic work-up”) to specific assessments of the components of the problem (“what is the probability ofStreptococcus pneumoniae bacteremia in a child with a temperature of 40.2°C and a white blood count of 16 000?”). Is the discussion of these issues more informed now than it was before publication of the guideline? Is there increased clarity regarding contentious clinical issues and important topics for research? I believe so, and to the extent this is the case, guidelines have served an important, though admittedly indirect, role in the enhancement of clinical care.
- Received March 11, 1997.
- Accepted March 31, 1997.
Reprints not available.
- Kramer MS,
- Shapiro ED
- Baraff LJ,
- Bass JW,
- Fleisher GR,
- et al.
- Copyright © 1997 American Academy of Pediatrics