The era of position statements and consensus documents: A source of clarity or confusion?

This issue of Paediatrics & Child Health includes a series of carefully selected articles on common gastrointestinal and nutritional disorders of childhood. The primary goal of this series is to provide the busy primary care practitioner and consultant paediatrician with up-to-date knowledge and a practical resource on how to evaluate and manage children with these common clinical problems. Most articles also offer advice concerning the indications for referring a patient to a subspecialist for additional consultative advice or evaluation. Do articles of this nature truly fulfill a need? Alternatively, is the busy paediatrician or family doctor likely to seek other sources of information to keep current with medical knowledge to guide their clinical practice? With the advent of the electronic era, practitioners now have instantaneous access to information that provide medical knowledge and advice on just about every medical ailment known to man. In fact, academic societies in every corner of the globe have entered into the business of generating a myriad of position statements and consensus reports on a variety of medical conditions. For example, the Web site of The American Gastroenterology Association offers 32 different position statements ranging from common conditions such as hemorrhoids and constipation to a policy statement on precertification of pharmaceuticals. Are these communications helpful to the busy medical practitioner? Do they offer up-to-the-minute, information on how to investigate, treat and monitor a specific disorder? Are they accurate and definitive, or are they biased by the self-interests of the membership of the association? Is the plethora of these communications causing confusion due to conflicting, dated or misleading information? To address some of these questions, we completed a Web-based search for position statements on a common condition of childhood and adulthood, “gastroesophageal reflux disease” (GERD). Freely accessible position statements on GERD were identified on the Web sites of four prominent North American gastroenterology societies: The American Gastroenterology Association (AGA [www.gastro.org]), American College of Gastroenterology (ACG [www.acg.gi.org]), Canadian Association of Gastroenterology (CAG [www.cag.acg.org]) and the North American Society for Paediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN [www.naspgn.org]). Table 1 summarizes the criteria we used to determine the validity and quality of each position statement as an up-to-date resource to guide the clinical practice of general paediatricians and family physicians treating infants and children with GERD. While the AGA, American College of Gastroenterology and CAG strive to attract subspecialty paediatricians as members and include gastrointestinal disorders of children as part of their respective mandates, all three position statements on GERD were authored solely by gastroenterologists who treat adults and were clearly written to provide guidance for the evaluation and treatment of adults with GERD. Furthermore, none of these publications contained explicit statements concerning their applicability (or lack) to infants and children. The dates of publication ranged from 1998 and 2002. Only one of the position statements (CAG) has been updated and only one (NASPGHAN) provides an analysis of the quality of evidence to support their recommendations. Three documents explicitly state that they are intended to provide guidance to primary care physicians. However, a closer analysis of the only position statement that focuses on infants and children with GERD (NASPGHAN) belies this assertion. Thirty-one pages of densely written script, five ‘user unfriendly’ diagnostic and management algorithms, and 336 citations hardly satisfy the needs of the busy primary care practitioner. Assessment of position statements on gastroesophageal reflux disease Web site states a third update is “coming soon”; Sponsored by a for profit pharmaceutical company. Members of the committee included a number of employees of pharmaceutical companies that market drugs for treating gastroesophageal reflux disease. ACG American College of Gastroenterology; AGA The American Gastroenterology Association; CAG Canadian Association of Gastroenterology; NASPGHAN North American Society for Paediatric Gastroenterology, Hepatology and Nutrition Assessment of position statements on gastroesophageal reflux disease Web site states a third update is “coming soon”; Sponsored by a for profit pharmaceutical company. Members of the committee included a number of employees of pharmaceutical companies that market drugs for treating gastroesophageal reflux disease. ACG American College of Gastroenterology; AGA The American Gastroenterology Association; CAG Canadian Association of Gastroenterology; NASPGHAN North American Society for Paediatric Gastroenterology, Hepatology and Nutrition Based on this simple analysis, we have concluded that, despite their best efforts, learned medical societies are unlikely to satisfy the educational needs of primary care practitioners. For this reason, it is our hope that the series of selected topics in paediatric gastroenterology published in this issue of Paediatrics & Child Health will provide busy physicians with more useful, practical advice on how to guide their clinical practice, than the plethora of confusing, dated and complex position statements that frequent electronic media.

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