In the present study, we sought to determine whether our pediatric group was adhering to the AAP's tobacco control and prevention guidelines and whether an educational outreach would increase physician adherence to the guidelines. In general, pediatricians screened at least 64% of families for second-hand smoke exposure. Counseling, however, was only conducted in 41% of clinic visits. After the educational outreach, the rate of counseling increased (P<0.05), but we found no statistically significant difference in the rate of screening, treatment, billing, or referral to quit lines. The reason for the visit was not predictive of whether pediatricians screened for tobacco smoke exposure.
Our results are in line with results from other studies assessing pediatricians' adherence to other clinical practice guidelines. The Bright Futures
guidelines were developed to improve the quality and consistency of care by providing pediatricians with specific recommendations for every WCC.21
The Patient Protection and Affordable Care Act states that providers must, at a minimum, provide preventive services as stated in the Bright Futures
A recent paper assessing adherence to the Bright Futures
guidelines, however, revealed that pediatricians are not following recommended guidelines.23
Mangione-Smith et al24
found that pediatric patients receive less than 50% of recommended preventive services. Several other studies have shown that pediatric healthcare providers are not adhering to basic preventive care, including recommendations for dental evaluation and referral,25
acute otitis media treatment,26
and overweight screening.27
We acknowledge that physician medical decisionmaking is complex and depends on many factors, such as physician experience and knowledge, patient characteristics and values, and weight of the clinical evidence.28
Isaac et al29
found that, in general, the AAP's guidelines are not always based on evidence but rather on expert opinion. We believe that the AAP's tobacco prevention and control recommendations are based on ample evidence1
and that their implementation should be strongly encouraged. If pediatricians are unwilling to treat parents' tobacco dependency, every effort should be made to refer them to smoking cessation services or parent support groups.30
A potential bias in our results is the heterogeneity of the comparison groups. We found a higher proportion of older patients in the preintervention group than the postintervention group. The number of WCC, sick nonrespiratory, and sick respiratory visits was significantly higher in the preintervention group compared to the postintervention group. These differences in patient characteristics reflect a real-world clinic that is likely to see patients of different ages at different times for different complaints. Pediatricians are encouraged to screen at every visit, regardless of the age or chief complaint. That the group with the higher rate of smoking exposure was also the group with the higher proportion of sick visits is of clinical interest.
Comparison of the 2 EMR systems at the institution revealed that neither was able to significantly impact physician adherence to tobacco control guidelines. Screening was not statistically different between them.