CLINICAL-PRACTICE GUIDELINES IN PEDIATRIC AND NEWBORN MEDICINE - IMPLICATIONS FOR THEIR USE IN PRACTICE

Clinical practice guidelines are becoming pervasive in pediatrics and newborn medicine. They have spanned a wide range of primary care pract ice parameters from treating otitis media with effusion, to performing complex surgery for congenital heart disease, and management of respi ratory distress syndrome and coordinating discharge from the neonatal intensive care unit. Administrators believe that using clinical practi ce parameters reduces health care costs, improves quality of care, and limits malpractice liability. Practice parameters and guidelines have grown in use because powerful interests-third-party payers, insurers, and health maintenance organizations, as well as hospital administrat ors bent on reducing variable costs of: care and contracting for capit ated care-champion their development, implementation, and monitoring. Economic credentialing of physicians with excessive variances without risk-adjusting for other than average patients is problematic and rema ins unchecked partly because of the fundamental characteristics of the evolving health care industry in which costs are more easily measured than quality. For highly autonomous physicians this standardization o f medical decision making may represent a difficult transition into co rporate practice by realigning traditional values of the doctor-patien t relationship. However, because guidelines are almost certainly here to stay, pediatricians and neonatologists need to think critically abo ut how their content and method of implementation, monitoring, and mod ification may influence medical teaching and decision making in the fu ture. If guidelines are introduced primarily as a cost savings or cont ainment tool that ignores the impact on the quality of care and restri cts necessary care for infants and children, especially those with chr onic illness or who are developmentally at risk, then neonatoIogists a nd pediatricians must be quick and determined to challenge the potenti ally damaging use of practice parameters or guidelines. Furthermore, t here are many medicolegal implications of guideline implementation tha t may not favor physicians and leave to hospitals, insurers, and ultim ately the courts decisions regarding evidence-based practice. In this review article, we pay special attention to the guidelines developed i n newborn medicine. We discuss why and how guidelines are developed an d critically evaluate the available evidence describing potential bene fits and drawbacks of guidelines in general. There are legal implicati ons to the implementation of guidelines, and guidelines may increase p rovider susceptibility to malpractice allegations. Neonatologists and pediatricians should critically analyze the following questions when g uidelines are being developed: Are clinical practice parameters the mo st effective means to reduce the costs of health care, or improve the quality of health care services while reducing the need for and protec ting physicians from malpractice suits' Or do clinical practice guidel ines more closely resemble an audit system developed by health care or ganizations, insurers, and others including government-sponsored healt h care to appease powerful interests-with limited evidence for promise and perhaps potential negative cost, quality, and malpractice liabili ty implications? In pediatric and newborn medicine there is limited ev idence that guidelines have achieved the desired goals and further ana lysis of their process of care and the costs of implementation is warr anted.