The development and use of evidence-based recommendations for preventive care by primary care providers caring for children is an ongoing challenge. This issue is further complicated by the fact that a higher proportion of recommendations by the US Preventive Services Task Force (USPSTF) for pediatric preventive services in comparison with adult services have insufficient evidence to recommend for or against the service. One important root cause for this problem is the relative lack of high quality screening and counseling studies in pediatric primary care settings. The paucity of studies limits the development of additional evidence-based guidelines to enhance best practices for pediatric and adolescent conditions. In this article, we describe the following: (1) evidence-based primary care preventive services as a strategy for addressing important pediatric morbidities, (2) the process of making evidence-based screening recommendations by the USPSTF, (3) the current library of USPSTF recommendations for children and adolescents, and (4) factors influencing the use of USPSTF recommendations and other evidence-based guidelines by clinicians. Strategies to accelerate the implementation of evidence-based services and areas of need for future research to fill key gaps in evidence-based recommendations and guidelines are highlighted.
Skip Nav Destination
Article navigation
August 2012
Special Article|
August 01 2012
USPSTF Perspective on Evidence-Based Preventive Recommendations for Children
Bernadette Mazurek Melnyk, PhD;
aCollege of Nursing and College of Medicine, The Ohio State University, Columbus, Ohio;
Address correspondence to Bernadette Melnyk, PhD, RN, CPNP/PMHNP, FNAP, FAAN, College of Nursing, The Ohio State University, Newton Hall, 1585 Neil Ave, Columbus, OH 43210. E-mail: melnyk.15@osu.edu
Search for other works by this author on:
David C. Grossman, MD;
David C. Grossman, MD
bGroup Health Research Institute, Group Health Cooperative, and Department of Health Services, University of Washington, Seattle, Washington;
Search for other works by this author on:
Roger Chou, MD;
Roger Chou, MD
cOregon Evidence-based Practice Center, Oregon Health and Science University, Portland, Oregon;
Search for other works by this author on:
Iris Mabry-Hernandez, MD;
Iris Mabry-Hernandez, MD
dCenter for Primary Care, Prevention, and Clinical Partnerships, Agency for Healthcare Research and Quality, Rockville, Maryland;
Search for other works by this author on:
Wanda Nicholson, MD;
Wanda Nicholson, MD
eDivision of Women's Primary Healthcare, Department of Obstetrics and Gynecology, University of North Carolina–Chapel Hill, Chapel Hill, North Carolina;
Search for other works by this author on:
Thomas G. DeWitt, MD;
Thomas G. DeWitt, MD
fDivision of General and Community Pediatrics, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;
Search for other works by this author on:
Adelita G. Cantu, PhD;
Adelita G. Cantu, PhD
gSchool of Nursing, University of Texas Health Science Center of San Antonio, San Antonio, Texas; and
Search for other works by this author on:
Glenn Flores, MD;
Glenn Flores, MD
hDivision of General Pediatrics, Southwestern Medical School, Children's Medical Center of Dallas, Dallas, Texas
Search for other works by this author on:
for the US Preventive Services Task Force
for the US Preventive Services Task Force
Search for other works by this author on:
Address correspondence to Bernadette Melnyk, PhD, RN, CPNP/PMHNP, FNAP, FAAN, College of Nursing, The Ohio State University, Newton Hall, 1585 Neil Ave, Columbus, OH 43210. E-mail: melnyk.15@osu.edu
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
Pediatrics (2012) 130 (2): e399–e407.
Article history
Accepted:
May 03 2012
Citation
Bernadette Mazurek Melnyk, David C. Grossman, Roger Chou, Iris Mabry-Hernandez, Wanda Nicholson, Thomas G. DeWitt, Adelita G. Cantu, Glenn Flores, for the US Preventive Services Task Force; USPSTF Perspective on Evidence-Based Preventive Recommendations for Children. Pediatrics August 2012; 130 (2): e399–e407. 10.1542/peds.2011-2087
Download citation file:
Sign in
Don't already have an account? Register
Pay-Per-View Access
$25.00
The Special Article by Melnyk, et al. highlights the challenges of implementing evidence-based guidelines for pediatric preventive services. [1] In addition to preventive care guidelines, pediatric specialists and professional organizations have developed a number of guidelines to improve care for children with chronic conditions such as ADHD[2], anxiety [3], asthma [4], depression[5, 6], headaches[7], and obesity[8]. Prevention and treatment guidelines are generally based not only on expert opinion, but optimally on systematic reviews and rigorously conducted randomized controlled clinical trials (RCTs). To minimize potential bias and confounding, RCTs are typically limited to subjects who are well or those with a single condition (excluding those with comorbidities). However, this approach, while methodologically rigorous, may not address the complex needs of a substantial number of children. Recently we began analyzing data from the 2007 National Health Interview Survey to compare the use of complementary and alternative medical (CAM) therapies among children with headaches alone vs. those with headaches plus one or more comorbid conditions (manuscript in preparation). Analyses were conducted with SAS version 9.3 for Windows (SAS Institute, Cary, NC); SAS-callable SUDAAN 10.0.1 (Research Triangle Institute, Research Triangle Park, NC) was used to report national estimates due to complex sampling design of NHIS. We were surprised that among those with recurrent headaches, fewer children had headaches alone (30.5%) than had headaches plus one or more chronic comorbid conditions (69.2%). This finding led us to examine other conditions from the same dataset for children <18 years old. For every condition we examined, a majority of children had one or more comorbid conditions, e.g., for those with ADHD (32% for the condition alone vs. 68.0% for ADHD plus one or more comorbid conditions); anxiety (18.6% anxiety alone vs. 81.4% with comorbidity), asthma (31% asthma alone vs. 69.0% with comorbidity), depression (6.0% depression alone vs. 94.0% with comorbidity), and obesity (38.1% obesity alone vs. 61.9% with comorbidity). The finding that children who have one chronic condition often or usually have one or more comorbid conditions confirms earlier individual reports for children with ADHD[9], asthma[10], and migraine headaches[11]. We support the suggestions to enhance the development and delivery of evidence-based practice guidelines for children and adolescence outlined by Melnyk, et al. [1] The high prevalence of comorbidities among children with common chronic conditions adds important implications for research and the implementation and evaluation of prevention/treatment guidelines. Current evidence-based guidelines developed based on data for children with a single condition may not be applicable to the majority of children who have multiple comorbid chronic conditions. An expanded research base is needed that includes rather than excludes those with comorbid conditions. Evaluating adherence to guidelines should include an analysis of the extent to which the guidelines are truly applicable to clinicians' clinical populations. This is particularly important in an era when payment will be tied to measures of quality. Improving the comprehensive, coordinated, personalized, preventive, and participatory care of children in greatest need (those with multiple chronic conditions) requires new approaches to research, guideline development, and evaluation.
Sincerely,
Kathi J Kemper, MD, MPH (Wake Forest University School of Medicine; kkemper@wakehealth.edu )
Gurjeet Birdee, MD, MPH (Vanderbilt University; gbirdee@vanderbilt.edu)
Paula Gardiner, MD, MPH (Boston University School of Medicine; Paula.Gardiner@bmc.org )
References
1. Melnyk, B.M., et al., USPSTF Perspective on Evidence-Based Preventive Recommendations for Children. Pediatrics, 2012.
2. Wolraich, M., et al., ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 2011. 128(5): p. 1007- 22.
3. Connolly, S.D. and G.A. Bernstein, Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry, 2007. 46(2): p. 267-83.
4. Shapiro, A., et al., Putting guidelines into practice: improving documentation of pediatric asthma management using a decision-making tool. Arch Pediatr Adolesc Med, 2011. 165(5): p. 412-8.
5. Cheung, A.H., et al., Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management. Pediatrics, 2007. 120(5): p. e1313-26.
6. Zuckerbrot, R.A., et al., Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics, 2007. 120(5): p. e1299-312.
7. Lewis, D., et al., Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society. Neurology, 2004. 63(12): p. 2215 -24.
8. Spear, B.A., et al., Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics, 2007. 120 Suppl 4: p. S254- 88.
9. Larson, K., et al., Patterns of comorbidity, functioning, and service use for US children with ADHD, 2007. Pediatrics, 2011. 127(3): p. 462-70.
10. de Groot, E.P., E.J. Duiverman, and P.L. Brand, Comorbidities of asthma during childhood: possibly important, yet poorly studied. Eur Respir J, 2010. 36(3): p. 671-8.
11. Lateef, T.M., et al., Physical Comorbidity of Migraine and Other Headaches in US Adolescents. J Pediatr, 2012. 161(2): p. 308-313 e1.
Conflict of Interest:
None declared
Sascha Meyer (MD)1, Wolfgang Girisch (MS)2, Christiane Willhelm (MD)2 University Hospital of Saarland, Department of Pediatrics and Neonatology; Section Neuropediatrics University Hospital of Saarland, Medical School 66421 Homburg, Germany Phone: +49(0)6841-1628374 Email: sascha.meyer@uks.eu
Regarding publication: USPSTF Perspective on Evidence-Based Preventive Recommendations for Children by Bernadette Mazurek Melnyk, David C. Grossman, Roger Chou, Iris Mabry-Hernandez, Wanda Nicholson, Thomas G. DeWitt, Adelita G. Cantu, Glenn Flores, and US Preventive Services Task Force; Pediatrics peds.2011-2087;
Dear Sir,
Evidence based medicine is considered an important contributor in providing the best quality of care in pediatrics, including the field of preventative child health. Mazurek Melnyk B. et al. state in their paper the development and use of evidence-based recommendations for preventive care by primary care providers caring for children is challenging (1). Of note, a higher proportion of recommendations by the US Preventive Services Task Force (USPSTF) for pediatric preventive services in comparison with adult services are inconclusive because of a lack of high quality screening and counseling studies in pediatric primary care settings (1). We would like to share similar experiences in the field of neuropediatrics and neonatology. We performed a literature review of all Cochrane Reviews published between 1996 and 2010 in paediatric neurology and neonatology (2, 3). The main outcome variable was: Percentage of reviews that concluded that a certain intervention provides a benefit, percentage of reviews that concluded that a certain intervention should not be performed, and percentage of studies that concluded that the current level of evidence is inconclusive. In neuropaediatrics, 112 reviews were enrolled; only 17 reviews included exclusively children. In 33/112 of reviews, a clear recommendation in favour of a certain intervention was given, 11/112 issued a conditional positive recommendation, while 32/112 reviews concluded that certain interventions should not be performed. Six reviews concluded that no differences were seen between different therapeutic/treatment options. Thirty reviews were inconclusive. The proportion of inconclusive reviews increased during 3, a priori defined time intervals. Common criticisms with regard to quality of enrolled studies included heterogeneous study populations (49/112), small number of study participants (48/112), and lack of comparability of studies (40/112).
In the field of neonatology, a total of 262 reviews were enrolled, most of which included exclusively preterm infants (146/262). The majority of reviews assessed pharmacological interventions (145/262); other important fields included nutritional (46/262), and ventilatory issues (27/262). In 42/262 reviews a clear recommendation in favor of a certain interventions was given, while 98/262 reviews concluded that certain interventions should not be performed. However, the largest proportion of reviews was inconclusive (122/262), and did not issue specific recommendations. The proportion of inconclusive reviews increased from 30% (1996-2000), to 50% (2001-2005), and finally to 58% for the years 2006- 2010. Common reasons for inconclusive reviews were small number of patients (105), insufficient data (94), insufficient methodological quality (87), and heterogeneity of studies (69).
We conclude that there is an ongoing need for high quality research in order to reduce the proportion of inconclusive meta-analysis. The realization of high quality research will in turn result in more systematic reviews that will come to a clear conclusion (i.e. in favor or against a certain intervention, or treatment modality, etc.). It will be of paramount importance that funding and research agencies will support those research programmes that address the most relevant issues in the field of neuropediatrics and neonatology. While our study focussed on practical issues, there is no question that Cochrane reviews play an outstanding role in providing systematic, up-to-date research data and importantly, generating and prioritizing new research questions for funding, action, and clinical collaboration - thus informing both practice and research audiences (3). Moreover, although Cochrane reviews are not a substitute for guidelines issued by national or international medical societies, the CNRG has acted as a driving force and promoter of implementing guidelines on a international and national level
References: 1) Bernadette Mazurek Melnyk, David C. Grossman, Roger Chou, Iris Mabry- Hernandez, Wanda Nicholson, Thomas G. DeWitt, Adelita G. Cantu, Glenn Flores, and US Preventive Services Task Force; USPSTF Perspective on Evidence-Based Preventive Recommendations for Children Pediatrics peds.2011-2087 2) Girisch W, Willhelm C, Gottschling S, Gortner L, Meyer S. Role of Cochrane reviews in pediatric neurology. Pediatr Neurol. 2012 Feb;46(2):63 -9. Review. 3) Willhelm C, Girisch W, Gortner L, Meyer S. Evidence-based medicine and Cochrane reviews in neonatology: quo vadis? Acta Paediatr. 2012 Apr;101(4):352-3. doi: 10.1111/j.1651-2227.2011.02559.x. Epub 2012 Jan 9. Review
Conflict of Interest:
None.