In the Literature

The Hospitalist. 2010 May;2010(05):

May 1, 2010 | The Hospitalist

Sameer Badlani, MD ; Stacy S. Banerjee, MD ; Alan J. Jung, MD ; Elizabeth Marlow, MD, MPP ; Valerie G. Press, MD, MPH ; Milda R. Saunders, MD, MPH ; Nilam J. Soni, MD Srilaxmi Tumuluri, MD ; University Of Chicago

PEDIATRIC HM LITERATURE

By Mark Shen, MD

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Less Is More in the Management of Acute Gastroenteritis

Clinical question: What is the effect of a guideline-training program for pediatricians on the management of acute gastroenteritis (AGE)?

Background: Guidelines recommending oral rehydration, early refeeding, and limited interventions have been developed for AGE management, but uptake by pediatricians has been slow. While individual components of these guidelines have been shown to be effective in comparison to other resource-intensive interventions, outcomes of global guideline implementation have not been studied well.

Study design: Prospective, randomized, controlled trial.

Setting: One hundred forty-nine primary-care pediatricians in Italy.

Synopsis: Pediatricians from the Italian national healthcare system were randomized to AGE guideline training or no training (usual practice; control group). The physicians enrolled 1,309 children in the study. Parents completed daily forms documenting the interventions for, and outcomes of, each illness.

Management by the trained group of pediatricians was in full compliance with the guidelines 66% of the time, as opposed to 33% of the time in the untrained group.

Significant differences between the groups were noted for each basic tenet of the guidelines: oral rehydration use, restrictive diets, medication use, and microbiologic testing. Notably, by both intention-to-treat and per-protocol analysis, the mean duration of diarrhea was shorter in children managed by the trained group of pediatricians.

As underadherence to evidence-based guidelines remains commonplace, effective implementation will become a greater area of focus. Despite a modest effect in an ambulatory population, these investigators demonstrated a clear improvement in outcomes with a simple, two-hour training program. While not studied, it is likely that the cost of care was significantly lower in the guideline group, given the dramatic differences in medication use and testing.

Bottom line: Effective implementation of AGE guidelines will improve outcomes and reduce costs.

Citation: Albano F, Lo Vecchio A, Guarino A. The applicability and efficacy of guidelines for the management of acute gastroenteritis in outpatient children: a field-randomized trial on primary care pediatricians. J Pediatr. 2010;156(2):226-230.