Commentary & Perspective

Commentary & Perspective on
"A Clinical Practice Guideline for Treatment of Septic Arthritis in Children. Efficacy in Improving Process of Care and Effect on Outcome of Septic Arthritis of the Hip"
by Mininder S. Kocher, MD, MPH, et al.

Commentary & Perspective by
G. Paul DeRosa, MD*,
Executive Director, The American Board of Orthopaedic Surgery, Chapel Hill, NC,
Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC

I congratulate the authors for their attempt to evaluate the efficacy of a clinical practice guideline that was developed by an interdisciplinary group of specialists for treatment of septic arthritis of all joints in children. I believe that the most important aspect of this work was the ability of physicians who treat infectious diseases, pediatricians, emergency medicine specialists, rheumatologists, radiologists, pharmacists, nurses, social workers, physical therapists, and orthopaedists to agree on the diagnosis and management of the relatively uncommon condition of septic arthritis of the hip in children.

Kocher et al. stated in the Discussion that a clinical practice guideline is not intended to replace clinical judgment, but I am concerned that some health-care organizations will attempt to impose it as the "gold standard" of care across the nation. This, of course, is not what the authors intended. Just as "all politics are local," so should be the formulation and implementation of clinical practice guidelines. Each individual institution is unique, and the local physicians, nurses, social workers, and other clinicians should engage in the exercise of reaching consensus on clinical practice guidelines within their own institutions.

That said, there are a few comments that I would like to make. A clinical practice guideline should take into account both the process and the outcomes of care. The first consideration is that no harm comes to the patient. In this study, Kocher et al. have shown that use of this clinical practice guideline resulted in greater standardization of care for patients with a relatively rare condition. They also showed that the outcomes were no different and also no worse when compared with those in a historical control group of children with septic arthritis of the hip managed before implementation of the guideline. Some of the differences in process parameters may simply be attributed to the evolution of medical care. For example, the use of C-reactive protein levels as a diagnostic test was not common in 1993, but it became routine in the year 2000. Patients now progress from intravenous to oral antibiotics more quickly than in the past. Of course, the individual child's response to surgical drainage and to intravenous antibiotics is the main determinant for this switch to oral antibiotics (Steps 13 through 17 of the CPG presented by Kocher et al.).

My major concern involves the older clinician reading this paper. The emphasis obviously has shifted from care of the individual patient to study of the process of care. We now need to read and think in a totally different fashion than was necessary in the past. The push to outpatient care is well recognized throughout the medical community, and the cost-shifting that accompanies that patient care is seen in today's medical environment as a "good" thing. We have to make ourselves conversant with concepts like the need for a "power analysis of 85% in order to determine a 20% reduction in hospital stay." We now need to discuss benchmark parameters of process and how they are evaluated. Although these new concepts and perspectives of clinical practice are valuable, they are more difficult for the older clinician to appreciate. However, I encourage The Journal of Bone and Joint Surgery to continue to present them.

Finally, for those of us who are educators, we must ensure that our young residents are, in fact, learning how to care for patients and not just how to implement the process of care. We must be certain that they understand the pathophysiology of joint-space infections, for example, and not simply reach for a set of orders to plug the patient into a preconceived protocol.

*The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.