BMJ 2014;348:g2056 doi: 10.1136/bmj.g2056 (Published 11 March 2014)
Page 1 of 2
Views & Reviews
VIEWS & REVIEWS FROM THE FRONTLINE
Bad medicine: NICE’s traffic light system for febrile children Des Spence general practitioner, Glasgow selected hospital populations, with 7% prevalence of bacterial infection,4 but this cannot be extrapolated in low risk community populations. So, what is the predictive value in the real world of primary care—where, through vaccination, serious bacterial infection is now rare and becoming ever rarer?5-7
The Centor criteria are used to diagnose bacterial tonsillitis. As a sceptic I always thought them flawed. The carriage of Streptococcus is so common, at 30-40%, that it makes the criteria’s predictive power meaningless. Also, the use of antibiotics has a limited effect on bacterial complications in rich countries.1
I was taught Centor in the traditional, absolutist medical way. Clinical rating scores are intellectually seductive, but do they stand up to scrutiny? Recent research has shown that the criteria may be ineffective in children and adolescents in predicting the presence of Streptococcus.2
The UK National Institute for Health and Care Excellence produces the “traffic light” clinical assessment system for children with fever, using red, amber, and green signs.3 It attempts to identify children with significant bacterial infections, meningitis, pneumonia, or septicaemia. This assessment guideline now infects all parts of the NHS, telephone triage systems, primary care, and emergency departments alike. Indeed, audits concentrate on recording respiratory rate, capillary refill, and heart rate, to enforce close adherence to the guideline. We assume that NICE guidelines have a strong evidence base and are clinically validated. But this is not the case. Although the guideline draws on clinical research the traffic light system is in fact based on the opinion and interpretation of a small panel of experts. As a practising clinician I disagree with some of this opinion. For example, “wakes only with prolonged stimulation”3 is considered amber; I would consider this absolutely a red flag. Also, the cited research is from
And in a recent attempt to clinically validate the traffic light system, research showed that the guideline had a very low specificity and low sensitivity.8 Here lies the potential for disastrous false positives and false negatives. Even for some of the best predictive clinical signs such as capillary refill, the confidence intervals are so wide as to make this a poor discriminator.4 Clinical assessment is in fact a rainbow coloured problem-solving affair based on experience, observation, continuity, and clinical intuition.9
So, what are the potential harms of this guideline? Unnecessary emergency ambulances being dispatched; unnecessary referrals and investigations; an unstoppable rise in emergency admissions10; more professional and parental paranoia; and, worst of all, false reassurance. Clinical signs are valuable, but NICE’s traffic light system needs rethinking: it is simultaneously overcomplicated and oversimplified, and it is clearly bad medicine. Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare. Provenance and peer review: Commissioned; externally peer reviewed. 1 2 3 4 5 6 7
Spinks A, Glasziou PP, Del Mar CB. Antibiotics for people with sore throats. Cochrane summaries. 5 Nov 2013. http://summaries.cochrane.org/CD000023/antibiotics-for-peoplewith-sore-throats#sthash.3pCmtffd.dpuf. Roggen I. Centor criteria in children in a paediatric emergency department: for what it is worth. BMJ Open 2013;3:e002712. Feverish illness in children: Assessment and initial management in children younger than 5 years. NICE clinical guidelines. May 2013. www.nice.org.uk/nicemedia/live/14171/63908/ 63908.pdf. Craig J. The accuracy of clinical symptoms and signs for the diagnosis of serious bacterial infection in young febrile children: prospective cohort study of 15 781 febrile illnesses. BMJ 2010;340:c1594. Whitney CG, Farley MM, Hadler J, Harrison LH, Bennett NM, Lynfield R, et al. Decline in invasive pneumococcal disease after the introduction of protein: polysaccharide conjugate vaccine. N Engl J Med 2003;348:1737-46. Collins S, Ramsay M, Campbell H, Slack MP, Ladhani SN. Invasive Haemophilus influenzae type b disease in England and Wales: who is at risk after 2 decades of routine childhood vaccination? Clin Infect Dis 2013;57:1715-21. Health Protection Scotland. Meningococcal infection. www.hps.scot.nhs.uk/resp/meningitismeningococcalinfection.aspx.
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Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g2056 doi: 10.1136/bmj.g2056 (Published 11 March 2014)
Page 2 of 2
VIEWS & REVIEWS
8 9
De S, Williams GJ, Hayen A, Macaskill P, McCaskill M, Isaacs D, et al. Accuracy of the “traffic light” clinical decision rule for serious bacterial infections in young children with fever: a retrospective cohort study. BMJ 2013;346:f866. Van den Bruel A, Thompson M, Buntinx F, Mant D. Clinicians’ gut feeling about serious infections in children: observational study. BMJ 2012;345:e6144.
10
Gill PJ, Goldacre MJ, Mant D, Heneghan C, Thomson A, Seagroatt V, et al. Increase in emergency admissions to hospital for children aged under 15 in England, 1999-2010: national database analysis. Arch Dis Child 2013;98:328-34.
Cite this as: BMJ 2014;348:g2056 © BMJ Publishing Group Ltd 2014
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
Page 1 of 2
Views & Reviews
VIEWS & REVIEWS FROM THE FRONTLINE
Bad medicine: NICE’s traffic light system for febrile children Des Spence general practitioner, Glasgow selected hospital populations, with 7% prevalence of bacterial infection,4 but this cannot be extrapolated in low risk community populations. So, what is the predictive value in the real world of primary care—where, through vaccination, serious bacterial infection is now rare and becoming ever rarer?5-7
The Centor criteria are used to diagnose bacterial tonsillitis. As a sceptic I always thought them flawed. The carriage of Streptococcus is so common, at 30-40%, that it makes the criteria’s predictive power meaningless. Also, the use of antibiotics has a limited effect on bacterial complications in rich countries.1
I was taught Centor in the traditional, absolutist medical way. Clinical rating scores are intellectually seductive, but do they stand up to scrutiny? Recent research has shown that the criteria may be ineffective in children and adolescents in predicting the presence of Streptococcus.2
The UK National Institute for Health and Care Excellence produces the “traffic light” clinical assessment system for children with fever, using red, amber, and green signs.3 It attempts to identify children with significant bacterial infections, meningitis, pneumonia, or septicaemia. This assessment guideline now infects all parts of the NHS, telephone triage systems, primary care, and emergency departments alike. Indeed, audits concentrate on recording respiratory rate, capillary refill, and heart rate, to enforce close adherence to the guideline. We assume that NICE guidelines have a strong evidence base and are clinically validated. But this is not the case. Although the guideline draws on clinical research the traffic light system is in fact based on the opinion and interpretation of a small panel of experts. As a practising clinician I disagree with some of this opinion. For example, “wakes only with prolonged stimulation”3 is considered amber; I would consider this absolutely a red flag. Also, the cited research is from
And in a recent attempt to clinically validate the traffic light system, research showed that the guideline had a very low specificity and low sensitivity.8 Here lies the potential for disastrous false positives and false negatives. Even for some of the best predictive clinical signs such as capillary refill, the confidence intervals are so wide as to make this a poor discriminator.4 Clinical assessment is in fact a rainbow coloured problem-solving affair based on experience, observation, continuity, and clinical intuition.9
So, what are the potential harms of this guideline? Unnecessary emergency ambulances being dispatched; unnecessary referrals and investigations; an unstoppable rise in emergency admissions10; more professional and parental paranoia; and, worst of all, false reassurance. Clinical signs are valuable, but NICE’s traffic light system needs rethinking: it is simultaneously overcomplicated and oversimplified, and it is clearly bad medicine. Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare. Provenance and peer review: Commissioned; externally peer reviewed. 1 2 3 4 5 6 7
Spinks A, Glasziou PP, Del Mar CB. Antibiotics for people with sore throats. Cochrane summaries. 5 Nov 2013. http://summaries.cochrane.org/CD000023/antibiotics-for-peoplewith-sore-throats#sthash.3pCmtffd.dpuf. Roggen I. Centor criteria in children in a paediatric emergency department: for what it is worth. BMJ Open 2013;3:e002712. Feverish illness in children: Assessment and initial management in children younger than 5 years. NICE clinical guidelines. May 2013. www.nice.org.uk/nicemedia/live/14171/63908/ 63908.pdf. Craig J. The accuracy of clinical symptoms and signs for the diagnosis of serious bacterial infection in young febrile children: prospective cohort study of 15 781 febrile illnesses. BMJ 2010;340:c1594. Whitney CG, Farley MM, Hadler J, Harrison LH, Bennett NM, Lynfield R, et al. Decline in invasive pneumococcal disease after the introduction of protein: polysaccharide conjugate vaccine. N Engl J Med 2003;348:1737-46. Collins S, Ramsay M, Campbell H, Slack MP, Ladhani SN. Invasive Haemophilus influenzae type b disease in England and Wales: who is at risk after 2 decades of routine childhood vaccination? Clin Infect Dis 2013;57:1715-21. Health Protection Scotland. Meningococcal infection. www.hps.scot.nhs.uk/resp/meningitismeningococcalinfection.aspx.
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g2056 doi: 10.1136/bmj.g2056 (Published 11 March 2014)
Page 2 of 2
VIEWS & REVIEWS
8 9
De S, Williams GJ, Hayen A, Macaskill P, McCaskill M, Isaacs D, et al. Accuracy of the “traffic light” clinical decision rule for serious bacterial infections in young children with fever: a retrospective cohort study. BMJ 2013;346:f866. Van den Bruel A, Thompson M, Buntinx F, Mant D. Clinicians’ gut feeling about serious infections in children: observational study. BMJ 2012;345:e6144.
10
Gill PJ, Goldacre MJ, Mant D, Heneghan C, Thomson A, Seagroatt V, et al. Increase in emergency admissions to hospital for children aged under 15 in England, 1999-2010: national database analysis. Arch Dis Child 2013;98:328-34.
Cite this as: BMJ 2014;348:g2056 © BMJ Publishing Group Ltd 2014
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
