Results

During the study period, 247 children were seen with 446 problems and a total of 1149 clinical actions were carried out. One hundred and forty questions were posed, which addressed 629 clinical actions. Table2 shows the numbers of questions by category and the corresponding numbers of clinical actions. Table 3 shows the quality of evidence determined for each category.

There was good evidence from a randomised controlled trial, systematic review, or another appropriate study for 39.9% of the clinical actions studied, and convincing non-experimental evidence for 7%. A further 9.7% of evidence was of good quality but was classed as inconclusive until the research findings could be confirmed in the community paediatric setting. Table 4 details the A1 evidence.

Figure 1 shows the good quality evidence by category. A substantial amount of good quality evidence was found for child health promotion and prescriptions, whereas least evidence was found to support counselling and advice. Even when immunisations were excluded from the analysis of child health promotion, 40% of actions were graded A1.

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Figure 1

Level of good evidence found for each category of clinical activity. A1, Good quality experimental evidence; A2, Convincing non-experimental evidence; B1, Good evidence but not clearly translatable to the community paediatric patient.

Discussion

Most of the interventions evaluated in general practice and inpatient general medicine were prescribed medications. Good experimental evidence was found for 53% of interventions in the general medicine paper2 and 31% of interventions in the general practice paper.3 Our study has shown that there is good experimental evidence for 53% of the prescriptions issued during the study period in community paediatrics. On a very simplistic basis it would be easy to state that there is as much good experimental evidence for community paediatric practice as the other specialties who have studied their evidence base.

However, our study was a refinement on the previously mentioned studies. In our study every clinical action carried out on patients was recorded, not just the action which on review seemed to be the principal one. Second, the quality of the evidence accepted was carefully assessed. Experimental evidence of effectiveness was only accepted if the study was methodologically sound and where the results were directly translatable to patients in a community paediatric setting.

Interestingly, because all clinical actions were recorded in our study, it was apparent that prescriptions accounted for only 3.7% of clinical actions performed during the study period. Clearly, stating that a specialty is evidence based when only the evidence of the effectiveness of treatments has been considered does not give the whole picture. There should also be clear evidence that diagnostic processes are effective (both clinical evaluation and relevant investigations), and for other components of the consultation, such as advice or reassurance given and referral to other professionals.

Community paediatrics involves more than seeing and treating acutely unwell children and making them well. Child health promotion, counselling and advice, and referral to other professionals are as important. They are included in the calculation that there is good evidence of effectiveness for 47%, and some evidence of effectiveness for a further 25% of the clinical actions in this community paediatric study.

In some areas disappointingly little evidence was found. Only 4% of the clinical evaluations made and 19% of the investigations carried out had clear evidence of accuracy or effectiveness in the community paediatric setting. Furthermore, the study highlighted the difficulties involved in assessing the accuracy of these diagnostic processes where studies would essentially be impossible to design. Further areas lacking in evidence were counselling/advice and referrals to other professionals.

It must be emphasised, however, that absence of evidence is not evidence of ineffectiveness,38 and the conclusion should therefore be that further research is required, rather than that these aspects of community paediatric practice are not worthwhile. Monitoring, liaison, multidisciplinary work, and statutory work are also an important part of community paediatrics. They were not evaluated in our study, and it is likely that the effectiveness or value of this type of work may best be answered by qualitative rather than quantitative research methods.

It was clear that overall there was a paucity of evidence from studies that had been carried out in the community or ambulatory paediatric setting. This meant that some good evidence was not given A1 status because we could not deem that the results were applicable to our patients. Examples included studies where counselling had been provided by a psychologist, or clinical evaluations had been carried out by tertiary specialists and where it could not be assumed that a community paediatrician would be similarly effective. Much research from hospital settings must be substantiated in the community setting before it can be considered applicable to community paediatricians and our broad spectrum of patients.

It is worthy of mention that so much of the clinical work of community paediatricians (identified by the process of keeping diaries) was found to be very similar to the work conventionally thought to be the province of hospital paediatricians. This suggests that the results of our study might well be extrapolated to the specialty of paediatrics as a whole.

The design of our study, which followed that of the studies in inpatient general medicine and general practice has both strengths and limitations. Using clinical encounters as the basis for searching for evidence ensures that common and important questions are answered. Reassuringly higher levels of evidence were found in all studies based on this design than those figures based on assessments of interventions that are high tech, high profile, and expensive.1 2

However, limitations were identified. Community child health tends to be seasonal and, because all the data collection for our study was carried out towards the end of the academic year, statutory work in school was underrepresented. Also underrepresented, by chance, were child protection and multidisciplinary work, both important aspects of community paediatrics. Our study also highlighted the need to ensure that clinical questions are well thought out and appropriate before searching databases.

Our study emphasises the need to ascertain the evidence underpinning all clinical actions, not simply “principal” interventions, which are often the easiest to search or indeed research. It should also be noted that searching for evidence can be time consuming. In preparing this paper 151 hours were spent doing electronic literature searches alone. It was estimated that these hours would be tripled when the time taken to find the journal articles and appraise them was included. Less than 50% of the group had access to a database at work or at home, and a number of journeys had to be made to the British Library to retrieve articles from some journals. If evidence based medicine is to become a reality, clinicians need easy access to electronic databases and good library support.