March 20, 2018

For better pediatric care, back guidelines with more evidence


In the 2000s, Dr. Beth McGlynn showed that rates of getting recommended care are low. In a new JAMA editorial, Dr. David Grossman has ideas to improve them

by David Grossman, MD, MPH, Kaiser Permanente Washington Health Research Institute (KPWHRI) senior investigator and pediatrician with Washington Permanente Medical Group

In 2003, a study by my colleague Dr. Beth McGlynn, vice president of Kaiser Permanente Research, set off discussions among physicians, health care system executives, and health policy experts across the country. At the time, Beth was director of the RAND Center for Research on Quality in Health Care. In the New England Journal of Medicine, she and her coauthors reported on an analysis of survey and medical record data from thousands of adults in 12 U.S. states, finding that adults received only 55 percent of recommended care.


In 2007, Dr. Rita Mangione-Smith, chief of the division of general pediatrics and hospital medicine at the University of Washington, with Beth and their colleagues, found even worse numbers for U.S. children: They received, on average, less than 46 percent of recommended care. In the two studies, the researchers found that for both adults and children, results varied by condition. However, the main lesson 10 years ago was clear: When it came to providing consistent care according to national guidelines, U.S. health care had a lot of room to improve.

The Quality of Ambulatory Care Delivered to Children in the United

Adherence to guidelines is still low

A new study in the Journal of the American Medical Association shows that rates of following clinical guidelines for pediatric care are still low and the problem is not limited to the United States. The report is from researchers in Australia and I was asked to write a companion editorial, “Quality of Health Care for Children: The Need for a Firm Foundation of Trustworthy Evidence” to their article.

Quality of Health Care for Children
Seventeen years have passed since the US National Academy of Medicine (NAM) (then the Institute of Medicine) published…

Consistent with the previous studies from the RAND group, the researchers found that in their country, only an estimated 60 percent of children receive treatments that adhere to clinical guideline recommendations. As a health care researcher, health system leader, and pediatrician, I understand that getting better at providing care according to guidelines means overcoming many challenges in multiple areas. But one that my colleagues and I at KPWHRI and other Kaiser Permanente research centers can address is generating evidence that may give physicians more confidence in the guidelines.

Clinicians want to provide the highest-quality care, but we’re not always certain about national recommendations and guidelines and how they apply to our patients. One detail I noticed in the Australian study was how little was known about the evidence behind the clinical practice guidelines that they used to assess adherence to recommended care; more than 74 percent lacked formal evidence grading. I believe that doctors treating both adults and children will have more confidence in guidelines when we know they are all supported by solid research findings.

An example is screening children for high blood lipids such as cholesterol. A recent study in Journal of Pediatrics found that less than half of U.S. pediatricians follow childhood lipid screening guidelines from, for example, the American Academy of Pediatrics. A companion commentary to the study notes that one reason for the low adherence to guidelines might be that the U.S. Preventive Services Task Force (USPSTF), of which I’m the chair, found insufficient evidence for a USPSTF recommendation about this practice.

A path to better guidelines

Pediatricians may be more likely to follow guidelines when rigorous research results indicate that they are the best way to have a positive effect on our patients’ health. We already have a compass pointing toward the research we need: The USPSTF published the key evidence gaps in children’s preventive services in its 2014 report to Congress.

Fourth Annual Report to Congress on High-Priority Evidence Gaps for Clinical Preventive Services …
Fourth Annual Report to Congress on High-Priority Evidence Gaps for Clinical Preventive

Almost 15 years ago, Beth McGlynn and colleagues began calling attention to the fact that many people are not receiving recommended care. There are many reasons for this shortfall. But health care researchers can help solve the problem of variable, low-quality, non-guideline-based care. We need to redouble our efforts to provide high-quality evidence for children’s health from randomized controlled trials, observational studies, pragmatic research conducted in close cooperation with health care systems, and other innovative projects. We can support our clinical colleagues who are trying to deliver the best care to each patient by providing them with quality evidence that makes health care guidelines stronger.

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