Clinical guidelines in 1994

The handling of urinary incontinence in Danish general practices after distribution of guidelines and voiding diary reimbursement: an observational study

BACKGROUND

Though urinary incontinence (UI) is a bothersome condition for the individual patient, the patients tend not to inform their physician about UI and the physician tend not to ask the patient. Recently different initiatives have been established in Danish general practices to improve the management of UI. The aim of this study was to identify the handling of urinary incontinence (UI) in Danish general practices after distribution of clinical guidelines and reimbursement for using a UI diary.

METHODS

In October 2001, a questionnaire was sent to 243 general practitioners (GPs) in Frederiksborg County following distribution of clinical guidelines in July 1999 (UI in general practice) and September 2001 (UI in female, geriatric, or neurological patients). A policy for a small reimbursement to GPs for use of a fluid intake/voiding diary in the assessment of UI in general practice was implemented in October 2001. Information concerning monthly reimbursement for using a voiding diary, prescribed drugs (presumably used for treating UI), UI consultations in outpatient clinics, and patient reimbursement for pads was obtained from the National Health Service County Registry.

RESULTS

Of the 132 (54%) GPs who replied, 87% had read the guidelines distributed 2 years before, but only 47% used them daily. The majority (69%) of the responding GPs had read and appreciated 1-3 other UI guidelines distributed before the study took place. Eighty-three percent of the responding GPs sometimes or often actively asked their patients about UI, and 92% sometimes or often included a voiding diary in the UI assessment. The available registry data concerning voiding diary reimbursement, prescribed UI drugs, UI consultations in outpatient clinics, and patient reimbursement for pads were insufficient or too variable to determine significant trends.

CONCLUSION

GPs management of UI in a Danish county may be reasonable, but low response rate to the questionnaire and insufficient registry data made it difficult to evaluate the impact of different UI initiatives.

A realistic approach to the evaluation of the quality management movement in health care systems: a comparison between European and African contexts based on Mintzberg's organizational models

The quality movement is gaining momentum worldwide in the field of health care. Initiated in industrialized countries, it steadily grows in Africa. However, there is no evidence that approaches designed to address issues in a given organizational context have the same effect in another one where issues present differently. Along the epistemological paradigm of realistic evaluation proposed by Pawson and Tilley, we use Mintzberg's organizational models to compare the configurations of European and African health care organizations and the trends followed by the quality management movement in both contexts. We illustrate how European health systems traditionally emphasize professional autonomy while African health systems are structured as command and control hierarchical systems. We illustrate how the quality movement in Europe emphasizes standardization of procedures, a characteristic of a mechanistic organization, while excessive standardization is part of the quality problem in Africa. We suggest that instilling professionalism may be a way forward for the quality movement in Africa to improve patient focus and responsiveness of responsible professionals. We also suggest that our interpretation of broad trends and contrasts may be used as a useful departure point to study the wide contextual diversity of the African experience with quality management.

Evidence-based medicine and hypertension

BACKGROUND

Evidence-based medicine (EBM) has been propagated as a revolutionary development which will improve the quality of clinical decision-making and guideline development Historically it follows an early 19th-century French attempt to introduce mathematical analysis into clinical practice. This met with resistance from both clinicians and scientists and was only accepted in more recent times with the development of clinical epidemiology and clinical trials.

NATURE OF EBM

EMB claims to utilize the best available evidence to reach scientific conclusions, rejecting the appeal to expert authority. This involves a hierarchy of sources which places large controlled trials at the apex. Less value is attributed to arguments from clinical observation or pathophysiology. Systematic reviews and meta-analyses of trials therefore provide the strongest evidence for clinical decisions.

THE CONCEPT OF EVIDENCE

The approach advocated in EBM is an over-simplification of the process of clinical thinking which involves interpretation and synthesis of relevant evidence from all sources and extrapolation to the clinical situation. In this process, there is no hierarchy of evidence. The relative value given to any particular evidence depends more upon its relevance and persuasiveness than the category to which it belongs. Discussion and debate amongst informed 'experts' is an integral feature of this process at each stage.

IMPACT OF EBM

Although advocates of EBM acknowledge the contribution of all forms of evidence, the differential value attached to different sources has led to naïve and simplistic attempts to omit the traditional processes of interpretation, synthesis and extrapolation and to draw wide-ranging conclusions from trial data without adequate scientific discussion.

Clinical guidelines: ways ahead

Clinical guidelines are essential in promoting the implementation of evidence-based practice within the NHS. But there are two broad schools of thought about their development and implementation: the first argues that guidelines should be entirely evidence-based and tolerates a degree of complexity which may make the guideline impractical; the second argues that we need simple guidelines, and sacrifices the strength of evidence in favour of ease of application and dissemination. Both arguments have merits and flaws, which are discussed, and ways to integrate the strengths of both are considered.

Population-based audit of colorectal cancer management in two UK health regions. Colorectal Cancer Working Group, Royal College of Surgeons of England Clinical Epidemiology and Audit Unit

BACKGROUND

To obtain information on the contemporary management of colorectal cancer in the UK to assist in the development of management guidelines, an independent, 1-year population audit was carried out in Trent Region and Wales.

METHODS

Data were collected on all patients admitted to hospital with a new diagnosis of colorectal cancer in a 1-year period.

RESULTS

Of 3520 patients, 3221 (91.5 per cent) had surgery. Emergency/urgent operations were carried out as the first procedure in 552 (17.1 per cent). Resection of the primary disease was achieved in 2859 (81.2 per cent) and this was deemed curative in 2070 (58.8 per cent). Twenty-one per cent of all patients had metastatic disease at presentation. Overall, 30-day operative mortality was 7.6 per cent (21.7 per cent for emergency/urgent and 5.5 per cent for scheduled/elective procedures). Anastomotic dehiscence occurred in 105 patients (4.9 per cent); this was 3.9 per cent after colonic resections and 7.9 per cent after anterior rectal resections. Elective rectal excision resulted in a permanent stoma in 486 of 1054 patients (46 per cent).

CONCLUSION

This initial report from a comprehensive, independent audit of colorectal cancer management shows improvement in some aspects of treatment as evidenced by improved anastomotic dehiscence and stoma rates when compared with previous studies. However, there has been little improvement in the proportion of patients presenting with advanced disease, and curative resection rates remain low.

Population-based audit of colorectal cancer management in two UK health regions. Colorectal Cancer Working Group, Royal College of Surgeons of England Clinical Epidemiology and Audit Unit

BACKGROUND

To obtain information on the contemporary management of colorectal cancer in the UK to assist in the development of management guidelines, an independent, 1-year population audit was carried out in Trent Region and Wales.

METHODS

Data were collected on all patients admitted to hospital with a new diagnosis of colorectal cancer in a 1-year period.

RESULTS

Of 3520 patients, 3221 (91.5 per cent) had surgery. Emergency/urgent operations were carried out as the first procedure in 552 (17.1 per cent). Resection of the primary disease was achieved in 2859 (81.2 per cent) and this was deemed curative in 2070 (58.8 per cent). Twenty-one per cent of all patients had metastatic disease at presentation. Overall, 30-day operative mortality was 7.6 per cent (21.7 per cent for emergency/urgent and 5.5 per cent for scheduled/elective procedures). Anastomotic dehiscence occurred in 105 patients (4.9 per cent); this was 3.9 per cent after colonic resections and 7.9 per cent after anterior rectal resections. Elective rectal excision resulted in a permanent stoma in 486 of 1054 patients (46 per cent).

CONCLUSION

This initial report from a comprehensive, independent audit of colorectal cancer management shows improvement in some aspects of treatment as evidenced by improved anastomotic dehiscence and stoma rates when compared with previous studies. However, there has been little improvement in the proportion of patients presenting with advanced disease, and curative resection rates remain low.

Do general practitioners want guidelines? Attitudes toward a county-based and a national college-based approach

OBJECTIVE

We carried out two studies (a and b) to assess general practitioners' attitudes towards a) regionally developed guidelines and b) guidelines developed by the Danish College of General Practitioners.

DESIGN

a) A randomized study among all GPs in Aarhus county comparing their attitudes towards guidelines in general and towards regional multidisciplinary developed guidelines on Pap-testing for cervical cancer, and b) a survey among all Danish GPs on attitudes towards earlier submitted guidelines for diabetes Type 2.

SETTING

GPs in Aarhus county and in all Denmark.

SUBJECTS

a) Questionnaires sent to 370 doctors in Aarhus county, and b) to 3471 GPs in all Denmark.

MAIN OUTCOME MEASURES

a) Attitudes to the known Pap guidelines compared with general attitudes. Themes in question were acceptance of guidelines, acceptance of multidisciplinary involvement, especially from the administrative staff, perceived effect on the consultation and the quality of care. In study b) remembrance of receiving, having read and used previous guidelines. Wishes with respect to future updates.

RESULTS

a) GPs were very positive towards the Pap guidelines they knew, and only few resisted. The number of positive answers was significantly fewer when doctors were asked about guidelines in general. b) There was an overwhelmingly positive attitude towards guidelines from the College on diabetes care and other topics relevant to GP work.

CONCLUSION

Danish GPs reported a very positive attitude towards the presented well-known guidelines on Pap testing and diabetes Type 2, and a fairly positive attitude towards hypothetical questions on guidelines in general.

The integration of evidence based medicine and personal care in family practice

Evidence based medicine is seductive in its simplicity and few would argue with the philosophical concept. The reality of its application in primary care is rather different. It is difficult to find evidence supporting many clinical management decisions, it may be difficult to interpret evidence when it is available, and it may be difficult to apply this evidence in the consultation. Clinical decisions may be influenced at many levels through health policy, audit, protocols, and guidelines, but the individual doctor patient relationship remains at the core of general practice. Developing a culture of evidence based medicine in general practice must integrate quantitative and qualitative research, epidemiology and psychology and the skills of public health and family medicine.

Defining evidence-based health care: A health-care learning strategy?

Health-care planners, policy makers, economists, purchasers and providers faced with increasingly limited resources, are attracted by the prospect of reliable evidence on costs and effectiveness1,2. The practice of evidence-based health care could ultimately lead to a redirection of resources towards treatments shown to be more effective than the alternatives. Evidence-based health care should extend the scientific methodologies to aspects of NHS activity other than clinical work. As a result there are wider cultural implications through the participation of staff in the identification of problems that are appropriately tackled by research3.

General practitioners' management of acute back pain: a survey of reported practice compared with clinical guidelines

OBJECTIVE

To compare general practitioners' reported management of acute back pain with 'evidence based' guidelines for its management.

DESIGN

Confidential postal questionnaire.

SETTING

One health district in the South and West region.

SUBJECTS

236 general practitioners; 166 (70%) responded.

OUTCOME MEASURES

Examination routinely performed, 'danger' symptoms and signs warranting urgent referral, advice given, and satisfaction with management.

RESULTS

A minority of general practitioners do not examine reflexes routinely (27%, 95% confidence interval 20% to 34%), and a majority do not examine routinely for muscle weakness or sensation. Although most would refer patients with danger signs, some would not seek urgent advice for saddle anaesthesia (6%, 3% to 11%), extensor plantar response (45%, 37% to 53%), or neurological signs at multiple levels (15%, 10% to 21%). A minority do not give advice about back exercises (42%, 34% to 49%), fitness (34%, 26% to 41%), or everyday activities. A minority performed manipulation (20%) or acupuncture (6%). One third rated their satisfaction with management of back pain as 4 out of 10 or less.

CONCLUSIONS

The management of back pain by general practitioners does not match the guidelines, but there is little evidence from general practice for many of the recommendations, including routine examination, activity modification, educational advice, and back exercises. General practitioners need to be more aware of danger symptoms and of the benefits of early mobilisation and possibly of manipulation for persisting symptoms. Guidelines should reference each recommendation and discuss study methodology and the setting of evidence.

Integrated care pathways: effective tools for continuous evaluation of clinical practice

The critical examination of clinical practice should be an integral part of patient care. It includes the development and implementation of guidelines, together with continuous evaluation of clinical process and outcomes to improve the quality of care provided. Clinical audit has not been successful in achieving this. The use of Integrated Care Pathways facilitates the introduction of guidelines and the continuous evaluation of clinical practice. Improvements are achieved by frequently revising the pathways to reflect current, local best practice. Integrated Care Pathways define the expected course of events in the care of a patient with a particular condition, within a set time-scale. A pathway is divided into time intervals during which specific goals and expected progress are defined, together with appropriate investigations and treatment. A pathway reflects the activities of a multidisciplinary team and can incorporate established guidelines and evidence-based medicine. It is usually unique to the institution in which it was developed. The pathway forms part of the clinical record of every patient. All variations from the pathway are documented, and the reasons for the variations analysed. Solutions are developed to address the causes of potentially avoidable variation, and the pathway is revised to incorporate these improvements. Integrated Care Pathways provide a powerful audit tool, as all aspects of the process and outcome of clinical practice can be constantly monitored. Variations from set standards are minimized, and improvements are rapidly incorporated into routine practice and subsequently re-evaluated.

Clinical guidelines in primary care: a survey of general practitioners' attitudes and behaviour

BACKGROUND

In the United Kingdom little is known about general practitioners' attitudes to and behaviour concerning clinical guidelines.

AIM

A study was performed to investigate these two under-researched areas.

METHOD

In 1994 a postal questionnaire on clinical guidelines was sent to all 326 general practitioner principals on the list of Lincolnshire Family Health Services Authority. The questionnaire consisted of 20 attitude statements and an open question on clinical guidelines, as well as surveying characteristics and behaviour of respondents.

RESULTS

Of the 326 general practitioners sent questionnaires, 213 (65%) replied. Most respondents (78%) reported having been involved in writing inhouse guidelines. An even greater proportion (92%) reported having participated in clinical audit. Respondents were generally in favour of clinical guidelines, with mean response scores indicating a positive attitude to guidelines in 15 of the 20 statements, a negative attitude in four and equivocation in one. The majority of respondents felt that guidelines were effective in improving patient care (69%). Members (or fellows) of the Royal College of General Practitioners had a more positive attitude than non-members towards guidelines. They were also significantly more likely than non-members to have written inhouse guidelines, as were those who had participated in audit compared with those who had not participated in audit. A substantial minority (over a quarter) of general practitioners were concerned that guidelines may be used for setting performance-related pay, or that they may lead to 'cookbook' medicine, reduce clinical freedom or stifle innovation. There was also concern that guidelines should be scientifically valid.

CONCLUSION

This study suggests that many general practitioners in the Lincolnshire Family Health Services Authority area have produced written inhouse guidelines. This is largely sustained by positive attitudes about the effectiveness and benefits of clinical guidelines. The positive attitude of RCGP members supports it in its continuing role in developing, implementing and evaluating guidelines in primary care. The question of whether incorporation of guidelines into clinical audit is an effective means to disseminate systematic research-based guidelines warrants further study.

The acute hot joint in medical practice

We have studied patients with acute hot joints presenting to general practice, casualty and inpatient rheumatology services. Their investigation, management and outcome were measured against guidelines. Different spectra of disease were seen in the different health care settings. The guidelines were not adhered to for crystal arthritis, particularly when it affected the first metatarso-phalangeal joints. The guidelines were broadly adhered to and useful for other joints, especially where septic arthritis was considered to be the likely diagnosis. We found no benefit on outcome from adhering to the guidelines. There was a tendency for the outcome to be worse where the guidelines were followed in full, suggesting that more investigations are performed in the more difficult cases. We conclude that drawing up guidelines for patient management is difficult even in an area where there is broad medical agreement.

Path.Finder: an interactive clinical information system. The day-to-day management of patients requires unified information sources

Presents Path.Finder, a locally managed health care information system built in response to the need for better communication of current research evidence and clinical practice guidelines. Concludes that this system will improve patient care by providing up-to-date, clinically useful information which is relevant locally. The technology and the information management system have been developed in parallel.