The challenge--and promise--of local clinical practice guidelines.

Clinical practice guidelines (CPGs) attempt to maximize the quality, efficiency, and cost-effectiveness of care delivered to patients by incorporating evidence-based recommendations into daily management. These can be developed on a national or professional society level, or they can be local endeavors. Resource availability, institutional culture, and local practice patterns can significantly impact local guideline development, resulting in marked heterogeneity between institutions. The article by Neuman et al in this issue of Pediatrics describes the variety of CPGs developed by freestanding children’s hospitals for the diagnosis and treatment of community-acquired pneumonia (CAP). Participating hospitals used either no local CPG or had implemented variousmeasures regarding diagnosis and management that, when compared between institutions, sometimes directly conflicted. The resulting analyses reflect the lack of impact one would expect with such variation. Only the most consistent recommendations—those that suggested specific antimicrobial regimens—demonstrated clinically significant differences between institutions that use or do not use CPGs. This is concerning, given that pediatricians, including trainees, use local CPGs more often than national guidelines for medical decision-making. National guidelines ideally serve to reduce unnecessary differences in resource use between providers and health care organizations. Expert panels sift through the morass of available data and expert opinion to find the pearls of best practice that providers will find useful and that will give maximal benefit to patients. Freed from the limitations of local resource and practice pattern constraints, such large-scale guidelines can provide a menu of diagnostic and treatment options and their relative levels of evidentiary support. This allows practitioners in diverse situations to optimally treat their patients by using a variety of recommended strategies. Equally important, national guidelines deliver proscriptions against outdated, ineffective, or harmful management practices, and they ideally foster treatment standardizations that result in outcome and cost benefits. However, the challenges to developing national guidelines and achieving actual improvements in patient care are identical to those for local CPGs: (1) finding sufficient evidence to validate recommendations, (2) demonstrating that guideline suggestions actually improve patient care, and (3) determining the optimal strategy for guideline dissemination and implementation. Multiple previous CPGs, although touted as instruments for cost savings and higher-quality care, have faced significant obstacles to implementation or have not resulted in the desired improvement in outcomes. In 2011, the Infectious Diseases Society of America and the Pediatric Infectious Diseases Society jointly published a national guideline on CAP management in infants and children.3months of age. The purpose of this guideline was to improve consistency of care nationally and to drive AUTHORS: Russell J. McCulloh, MD and Brian K. Alverson, MD