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. 2022 May 17;17(5):e0267445.
doi: 10.1371/journal.pone.0267445. eCollection 2022.

Mind the gap: Mapping variation between national and local clinical practice guidelines for acute paediatric asthma from the United Kingdom and the Netherlands

Charlotte Koldeweij  1   2 , Nicholas Appelbaum  2   3 , Carmen Rodriguez Gonzalvez  2 , Joppe Nijman  4 , Ruud Nijman  5 , Ruchi Sinha  6 , Ian Maconochie  7 , Jonathan Clarke  3   8
Affiliations

Mind the gap: Mapping variation between national and local clinical practice guidelines for acute paediatric asthma from the United Kingdom and the Netherlands

Charlotte Koldeweij et al. PLoS One. .

Abstract

Background: Clinical practice guidelines (CPGs) aim to standardize clinical care. Increasingly, hospitals rely on locally produced guidelines alongside national guidance. This study examines variation between national and local CPGs, using the example of acute paediatric asthma guidance from the United Kingdom and the Netherlands.

Methods: Fifteen British and Dutch local CPGs were collected with the matching national guidance for the management of acute asthma in children under 18 years old. The drug sequences, routes and methods of administration recommended for patients with severe asthma and the tone of recommendation across both types of CPGs were schematically represented. Deviations from national guidance were measured. Variation in recommended doses of intravenous salbutamol was examined. CPG quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II.

Results: British and Dutch national CPGs differed in the recommended drug choices, sequences, routes and methods of administration for severe asthma. Dutch national guidance was more rigidly defined. Local British CPGs diverged from national guidance for 23% of their recommended interventions compared to 8% for Dutch local CPGs. Five British local guidelines and two Dutch local guidelines differed from national guidance for multiple treatment steps. Variation in second-line recommendations was greater than for first-line recommendations across local CPGs from both countries. Recommended starting doses for salbutamol infusions varied by more than tenfold. The quality of the sampled local CPGs was low across all AGREE II domains.

Conclusions: Local CPGs for the management of severe acute paediatric asthma featured substantial variation and frequently diverged from national guidance. Although limited to one condition, this study suggests that unmeasured variation across local CPGs may contribute to variation of care more broadly, with possible effects on healthcare quality.

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Conflict of interest statement

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: two authors (NA and CK) had support from the National Institute for Health Research and one author (JC) had support from the Wellcome Trust for the submitted work. NA is the CEO of Dosium, a software company building decision support tools for medication safety. Authors had no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

Fig 1
Fig 1. Variation across treatment pathways for most severe acute paediatric asthma across British and Dutch CPGs.
Drug recommendations proceed from left to right. Iv: intravenous, neb: nebulized.
Fig 2
Fig 2. Recommended dose ranges for continuous salbutamol infusions across sampled CPGs from the UK and the Netherlands.
Hatching indicates starting dose ranges. The arrow indicates the absence of a maximum dose recommended by the concerned guideline. UK2 and UK5: maximum doses calculated for a child of 10 kilograms based on the absolute maximum dosages recommended by each CPG.
See this image and copyright information in PMC

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References

    1. Wolf JS, Hubbard H, Faraday MM, Forrest JB. Clinical practice guidelines to inform evidence-based clinical practice. World J Urol 2011;29;303–9. doi: 10.1007/s00345-011-0656-5 - DOI - PubMed
    1. Djulbegovic B, Guyatt GH. Progress in evidence-based medicine: a quarter century on. Lancet 2017;390:415–23. doi: 10.1016/S0140-6736(16)31592-6 - DOI - PubMed
    1. Institute of Medicine (U.S.). Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. Clinical practice guidelines we can trust [Internet]. Washington DC;2011[cited 2020 Jun 23]. 266 p. Report No: 978-0-309-16422-1. Available from: https://www.ncbi.nlm.nih.gov/books/NBK209539/.
    1. Djulbegovic B, Hozo I, Dale W. Transforming clinical practice guidelines and clinical pathways into fast-and-frugal decision trees to improve clinical care strategies. J Eval Clin Pract 2018;24:1247–54. doi: 10.1111/jep.12895 - DOI - PubMed
    1. Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical guidelines. Potential benefits, limitations, and harms of clinical guidelines. BMJ 1999;318:527–30. doi: 10.1136/bmj.318.7182.527 - DOI - PMC - PubMed

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