A careless shoe-string, in whose tieI see a wild civility:Do more bewitch me, than when artIs too precise in every part. “Delight in Disorder,” Robert Herrick (1591–1674)
Herrick's 17th-century sonnet seems the antithesis of the scientific movement toward evidence-based medicine. And, of course, it mostly is: there is no place for the “careless” or the “wild.” Yet those of us who still exalt in the “art” of medicine are less “bewitched” when guidance becomes “too precise in every part.” This is a subversive sentiment and, if applied to our patients, must be done so thoughtfully and responsibly. However, it may lead us to a useful insight: evidence-based medicine is not incompatible with significant practice variation.
In this month's issue of Pediatrics, Goldman et al1 describe (with a perceptible sense of dismay) practice variation across Canadian pediatric emergency departments in the management of febrile infants younger than 90 days. Although most infants had blood and urine work performed, the authors are particularly struck by the variability in lumbar puncture rates. They imply that such variability is hard to justify in the face of the availability of “several clinical guidelines” for the management of such children. They conclude with a call to devise “translation strategies” for practitioners regarding what is known about the management of febrile infants (presumably to limit such variation).
But, what is known about the management of febrile infants? And, does such a fund of knowledge comprise an evidence base from which deviation is unjustified? Sometimes it is easier. The evidence is overwhelming, risk/benefit approaches are obvious, and “expert” consensus is wide-ranging and multidisciplinary. The American Academy of Pediatrics guidelines regarding hyperbilirubinemia in normal newborns or even the treatment and workup of urinary tract infections come to mind.2,3 No such case can be made for febrile infants. There has really only been 1 document (simultaneously published in 2 journals) bold enough to term itself a “guideline,” and it is controversial.4,5 The controversy stems not from the strength of the evidence (although that has been questioned) but, rather, from the conclusions of these experts as to how this evidence should dictate practice.6
Economists observed many years ago that human behavior and decisions reflect variations in personal risk aversion. As Green and Rothrock7 emphasized a decade ago, individual practitioners will vary in their tolerance of risk. Goldman et al note that “incompliance” with the guidelines may be “associated … with the physicians.”1 This is true, but it is no bad thing. Two practitioners can be completely informed, aware, and have internalized all the relevant data regarding the risk of serious bacterial infection (SBI) in a given instance and still justifiably differ in their management approaches. One may weigh the risk of SBI against the risk of iatrogenesis (eg, a contaminated tap), unnecessary hospitalization, costs, etc and find the balance of “evidence” to lead him or her to forego a full sepsis workup. Another reasonable provider might come to a different conclusion. These practitioner differences in risk tolerance do not even account for the parents' wishes, which add yet another layer of variability to the decision-making process.8
Goldman et al seem frustrated that their “study of a relatively homogenous group of pediatric emergency physicians still showed significant practice variation.”1 However, it is exactly this subset of practitioners who care for children who should be best informed about the risks, costs, and benefits of their decisions regarding a workup for SBI. This article's findings really speak to the variation in the views of the individuals who comprise this subspecialty regarding the validity of the “guidelines,” which the authors approach as a settled question. I would expect these providers to be the ones most likely to confidently challenge the tyranny of a cookbook approach when their own assessment of the evidence leads them to a different conclusion. As mentioned above, individual clinical decisions may not be “homogenous” even in the face of common training backgrounds and uniformly accepted evidence.
Almost 30 years ago Wennberg and his Dartmouth colleagues9 first rattled the modern medical establishment by pointing out variations in practice that led to variations in costs without demonstrable effects on outcomes. The assumption was that such variation must be unjustified, and explanations were demanded: physicians were lazy creatures of habit; a small number of “opinion leaders” dominated regions; nefarious financial influences were at play; etc. There were more charitable explanations as well, of course, but the ultimate thesis is that such variation, in the absence of improved outcomes, is unjustified.10
Now back to febrile infants. Fortunately, SBI is rare, and morbidity rates are low. Not one scintilla of evidence has linked any particular management approach to a difference in health outcomes (although costs clearly differ).11 Those who would use Wennberg's reasoning to indict the “careless shoestrings” who dare to stray from published interpretations of proper management are lacking an essential element, that is, the link to outcomes. Could our field bring us the evidence necessary to derive outcome-based guidelines that could define what is too risky or what is too costly? Perhaps someday. But, until then, because responsible practitioners, parents, and institutions all think for themselves, the management of febrile infants will be delightfully disordered.
I thank Genie Roosevelt, MD, MPH, and Lalit Bajaj, MD, MPH, for thoughtful comments on drafts of this commentary.
- Accepted January 20, 2009.
- Address correspondence to Louis C. Hampers, MD, MBA, University of Colorado School of Medicine, Section of Pediatric Emergency Medicine, 13123 E 16th Ave, B251, Aurora, CO 80045. E-mail:
Financial Disclosure: The author has indicated he has no financial relationships relevant to this article to disclose.
- ↵Goldman RD, Scolnik D, Chauvin-Kimoff L, et al. Practice variation among pediatric emergency physicians in the management of febrile infants 0–90 days of life. Pediatrics.2009;124 (2):439– 445
- ↵American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation [published correction appears in Pediatrics. 2004;114(4):1138]. Pediatrics.2004;114 (1):297– 316
- ↵American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Urinary Tract Infection. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children [published corrections appear in Pediatrics. 2000;105(1 pt 1):141, 1999;103(5 pt 1):1052, and 1999;104(1 pt 1):118]. Pediatrics.1999;103 (4 pt 1):843– 852
- ↵Baraff LJ, Bass JW, Fleisher GR, et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Agency for Health Care Policy and Research [published correction appears in Ann Emerg Med. 1993;22(9):1490]. Ann Emerg Med.1993;22 (7):1198– 1210
- ↵Kramer MS, Shapiro ED. Management of the young febrile child: a commentary on recent practice guidelines. Pediatrics.1997;100 (1):128– 134
- ↵Kramer MS, Etezadi-Amoli J, Ciampi A, et al. Parents' versus physicians' values for clinical outcomes in young febrile children. Pediatrics.1994;93 (5):697– 702
- ↵Wennberg JE. Administrators must pursue policies that reduce excess beds, employees. Health Manage Q. 1984–1985;winter :6– 7
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