Journal of Pediatric Gastroenterology & Nutrition:
Division of Pediatric Gastroenterology, University of California-San Francisco.
Address correspondence and reprint requests to M. Michael Thaler, MD, Box 0136, University of California-San Francisco, San Francisco, CA 94143 (e-mail: ThalerM@peds.ucsf.edu).
Received 22 November, 2013
Accepted 25 November, 2013
The author reports no conflicts of interest.
See “Gastroesophageal Reflux Guidelines: The European Experience” by McCracken on page 395, and “European Pediatricians’ Approach to Children With GER Symptoms: Survey of the Implementation of 2009 NASPGHAN-ESPGHAN Guidelines” by Quitadamo et al on page 505.
In 2012, a survey of pediatricians from 11 European countries indicated that a vanishingly small handful (1.8%) of self-selected respondents applied the 2009 NASPGHAN-ESPGHAN clinical practice guidelines for GER. In the previous commentary, McCracken approaches the survey results from a practical perspective by postulating putative barriers to implementation: ignorance of the guidelines owing to inadequate publicity, lack of clarity as a result of rapid turnover in recommendations, impractical requirements, and parental resistance to recommended diagnostic procedures. McCracken understandably argues that once these obstacles are removed, compliance with the guidelines should improve.
These are plausible explanations for the noncompliance, but they cannot be reliably tested. The authors themselves concede that “the analysis of the questionnaires does not allow us to comment on the reasons for the European pediatricians’ failure to comply with recommendations, and therefore does not suggest specific interventions.” Thus, the survey does not offer or suggest trustworthy answers for poor adherence to official guidelines. Nevertheless, the survey is worthy of publication as the results generate interesting and getatable questions.
Most notable is the lack of comparative data from non-European settings. Only when similar surveys are conducted in other contexts can we begin to ask what drives regional differences in diagnostic and therapeutic approaches to common yet vaguely characterized complaints such as “irritability.” For example, what if implementation of guidelines is no better in the United States than in Europe? What if compliance is higher in the United States, but not in Canada or vice versa? What do we find when Argentina is compared with Spain and Brazil compared with Portugal?
I believe the answers to these questions are attainable and would shed light on the results of the European survey. With comparable data in hand, we may eventually hope to address larger issues that are beyond the scope of the present survey. These include the influence of traditional practice patterns and national health care systems, the threat of malpractice suits, and the application of the latest advances, on compliance with criterion standard clinical guidelines by pediatric practitioners.