Pediatric Informatics: Computer Applications in Child Health (Health ...

122 A. Matlow and J.M.A. Bohnen
Proposed Solution
Embed a pop-up into computerized surgical preoperative order sets, such that when
the antibiotic is entered, the physician would be reminded that the drug should be
administered within 60 min prior to the incision.
Some limitations of CPGs are listed in Table 9.1. The CPGs themselves may
be problematic. Alternatively, problems with physician adherence may limit their
applicability. 13 In a survey of pediatricians about their knowledge and practice of
four CPGs (management of the febrile infant, neonatal hyperbilirubinemia, otitis
media with effusion, and preventive care), Christakis et al. 14 found that knowledge
of the guidelines ranged from 16–66%, assessment of mean helpfulness scores
(1–10 scale, where 1 = “not at all helpful” and 10 = “extremely helpful”) ranged
from 3.67 to 6.67, and change in patient management based on the guidelines
ranged from 19–36% for the four guidelines. More recent graduation from medical
school and increased helpfulness scores were associated with more guidelinerelated
behavior change by providers. Variability in actual implementation was
recently further borne out in a review of compliance with the AAP’s CPG on
management of first urinary tract infection (UTI) in infants, in which recommendations
include timely imaging, and adequate antimicrobial prophylaxis. 15 The
authors reviewed Washington State’s Medicaid data, on in-patients and out-patients
diagnosed with a UTI within the first year of life, and found that overall, only 44%,
39.5%, and 51% of eligible patients received anatomic imaging, imaging for reflux
and antimicrobial prophylaxis where warranted respectively.
In 2003, the Centers for Medicare and Medicaid Services embarked on a large
pay-for-performance pilot project using the American College of Cardiology/
American Heart Association guidelines for acute myocardial infarction. The goal
of pay-for-performance programs is to tie financial incentives to adherence with
guidelines. 16 However, Walter et al. have recently drawn attention to problems in
using adherence to guidelines as a measure of quality of care. 17 Studying compliance
with colorectal cancer screening guidelines, the authors identified the following as
limitations to using adherence rates to guideline-based performance measures
Table 9.1 Limitations of clinical practice guidelines
Technical (guideline-related) limitations Adaptive (physician-related) limitations
Recommendations are wrong Users have limited knowledge
Are open to subjective interpretation Lack awareness of guidelines
Contain outdated content Lack familiarity with guidelines
Recommendations limit freedom of choice Users have implementation limitations
Negatively influence resource allocation Disagree with recommendations
Do not take patient preferences into account Lack self efficacy
Reduce flexibility for special needs patients Lack outcome efficacy
Recommendations do not reach target audience Resist change (practice inertia)
Recommendations discourage research
Recommendations increase costs of care