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. 2012 Jul;130(1):93-8.
doi: 10.1542/peds.2011-3811. Epub 2012 Jun 4.

Dynamic evolution of practice guidelines: analysis of deviations from assessment and management plans

Michael Farias  1 , Kevin G Friedman, Andrew J Powell, Sarah D de Ferranti, Audrey C Marshall, David W Brown, Thomas J Kulik
Affiliations

Dynamic evolution of practice guidelines: analysis of deviations from assessment and management plans

Michael Farias et al. Pediatrics. 2012 Jul.

Abstract

Objective: A Standardized Clinical Assessment and Management Plan (SCAMP) standardizes the care of patients with a predefined diagnosis while actively inviting and collecting data on clinician deviations (DEVs) from its recommendations. For 3 different pediatric cardiac diagnoses managed by SCAMPs, we determined the frequency of, types of, and reasons for DEVs, which are considered to be a valuable source of information and innovation.

Methods: DEVs were collected as part of SCAMP implementation. DEVs were reviewed by the SCAMP committee chairperson and by a separate protocol deviation committee; they were characterized as either justifiable (J), possibly justifiable (PJ), or not justifiable (NJ).

Results: We analyzed 415 patients, 484 clinic encounters, and 216 DEVs. Eighty-six (39.8%) of the DEVs were J, 21 (9.7%) were PJ, and 109 (50.4%) were NJ. The percentage of NJ DEVs relative to the number of opportunities for DEV was 4.1%. J and PJ DEVs were mostly due to management of unrelated conditions (11% overall) or special circumstances (22% overall). NJ DEVs primarily involved follow-up intervals (66%) and deleted tests (24%). The reason for deviating from SCAMP recommendations was not given for 31% of DEVs, even though such information was requested.

Conclusions: The overall low rate of NJ DEV suggests that practitioners generally accept SCAMP recommendations, but improved capture of practitioners' reasons for deviating from those recommendations is needed. This analysis revealed multiple opportunities for improving patient care, suggesting that this process can be useful in both promulgating sound practice and evolving improved approaches to patient management.

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Conflict of interest statement

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Figures

FIGURE 1. Summary of the SCAMP DEV analysis process.
FIGURE 1
Summary of the SCAMP DEV analysis process.
FIGURE 2. The reasons why a DEV was judged to be J or PJ. The percentages refer to the percentage of all DEVs in that disease type accounted for by the particular reason (eg, Unrelated Condition). ALL indicates all 3 disease types combined (AS, ASO, and HCM).
FIGURE 2
The reasons why a DEV was judged to be J or PJ. The percentages refer to the percentage of all DEVs in that disease type accounted for by the particular reason (eg, Unrelated Condition). ALL indicates all 3 disease types combined (AS, ASO, and HCM).
FIGURE 3. The reasons why a DEV was judged to be NJ. The percentages refer to the percentage of all DEVs in that disease type accounted for by the particular reason (eg, Family Preference). ALL indicates all 3 disease types combined (AS, ASO, and HCM).
FIGURE 3
The reasons why a DEV was judged to be NJ. The percentages refer to the percentage of all DEVs in that disease type accounted for by the particular reason (eg, Family Preference). ALL indicates all 3 disease types combined (AS, ASO, and HCM).
FIGURE 4. The percentage distribution of the kinds of NJ DEVs for all 3 diagnoses combined (AS, ASO, and HCM; N = 109).
FIGURE 4
The percentage distribution of the kinds of NJ DEVs for all 3 diagnoses combined (AS, ASO, and HCM; N = 109).
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