Over the last 10 years, the AAOS has invested a great deal of effort and resources into developing Clinical Practice Guidelines (CPGs) and Appropriate Use Criteria. One rationale for these efforts was to follow the lead of our cardiovascular brethren, who have disseminated the highest level of evidence available to their community to help ensure that clinical decision making, in collaboration with the patient and family, is supported by the most solid science.
The paper published in the October 21, 2015 edition of JBJS by Oetgen et al. provides us with an evaluation of the impact of CPGs in managing femoral shaft fractures in children. The authors performed detailed chart reviews on 361 patients treated for a pediatric diaphyseal femoral fracture between 2007 and 2012. They analyzed each patient record to determine whether age-specific CPGs—which were published for this condition in 2009—were followed.
The results are somewhat discouraging. Oetgen et al. identified little if any impact of the CPG on clinical practice. Is that because surgeons are unaware of these tools? Or do they feel they know better than the literature synthesis at their disposal? Without more research, we will not know the answer to that question, but I suspect that recognition of the utility of CPGs will take a decade at least. I have the impression that younger surgeons are more accepting of the concepts of meta-analysis and levels of evidence as they influence clinical decision making—and as they were utilized to develop CPGs. Waiting longer to make judgments about the impact of CPGs seems appropriate.
There is another factor also. These documents are guidelines, not restrictive formulas. Oetgen et al. emphasize that point in their introduction. Physicians everywhere wish to retain the privilege of making the best educated decision for each patient and family; this fact is partly responsible for the pushback that AAOS leadership received when starting down the CPG path. Additionally, during decision making for children with femoral shaft fractures, parental preferences will play a very strong role, regardless of the guidelines. This reality may ultimately limit efforts to accurately measure the clinical impact of CPGs by analyzing administrative databases.
So let’s give these guidelines a little more time to mature, and let’s give our orthopaedic community more time to become familiar with the utility of these documents. And, above all, let’s not turn guidelines into “cookbook” patterns of clinical decision making. Inputs from the treating physician, patient, and family should always be preeminent.
Marc Swiontkowski, MD