Mind the gap: Mapping variation between national and local clinical practice guidelines for acute paediatric asthma from the United Kingdom and the Netherlands

Abstract

Background Clinical practice guidelines (CPGs) aim to standardize clinical care. Increasingly, hospitals rely on locally produced guidelines alongside national guidance. This study examines variation between national and local CPGs, using the example of acute paediatric asthma guidance from the United Kingdom and the Netherlands. Methods Fifteen British and Dutch local CPGs were collected with the matching national guidance for the management of acute asthma in children under 18 years old. The drug sequences, routes and methods of administration recommended for patients with severe asthma and the tone of recommendation across both types of CPGs were schematically represented. Deviations from national guidance were measured. Variation in recommended doses of intravenous salbutamol was examined. CPG quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II. Results British and Dutch national CPGs differed in the recommended drug choices, sequences, routes and methods of administration for severe asthma. Dutch national guidance was more rigidly defined. Local British CPGs diverged from national guidance for 23% of their recommended interventions compared to 8% for Dutch local CPGs. Five British local guidelines and two Dutch local guidelines differed from national guidance for multiple treatment steps. Variation in second-line recommendations was greater than for first-line recommendations across local CPGs from both countries. Recommended starting doses for salbutamol infusions varied by more than tenfold. The quality of the sampled local CPGs was low across all AGREE II domains. Conclusions Local CPGs for the management of severe acute paediatric asthma featured substantial variation and frequently diverged from national guidance. Although limited to one condition, this study suggests that unmeasured variation across local CPGs may contribute to variation of care more broadly, with possible effects on healthcare quality.

Emergency department discharge practices for children with acute wheeze and asthma: a survey of discharge practice and review of safety netting instructions in the UK and Ireland

“…Establishing dose-response data for inhaled salbutamol in young children is challenging due to obstacles including disease heterogeneity and disagreement on thresholds for clinically significant bronchodilator responsiveness 23 24. International recommendations for bronchodilator dosing during acute asthma attacks are typically consensus-based and differ slightly,7 25–28 contributing to variation in acute management including type, route and dosage of bronchodilators and steroid usage 29 30…”