Development of clinical guidelines in a health district: an attempt to find consensus

[Long-term usefulness of an information programme on practices in surgical antimicrobial prophylaxis]

INTRODUCTION

In France, numerous concordant studies show that there are some discrepancies between guidelines on surgical antibiotic prophylaxis and the current practice. In a previous study, conducted in April-June 2001, we found that the rate of appropriateness of surgical antimicrobial prophylaxis was approximately 40%. An information programme was implemented and the purpose of this paper was to present the short- and long-term usefulness of this campaign.

METHODS

A total of 13 pairs of surgeons/anaesthetists participated in data collection during the three periods of the study. Prescriptions were observed in order to answer to five questions. Five variables describing practices concerning antibiotic prophylaxis in surgery were compared to national recommendations (updated in 1999): did the surgical procedure require antibiotic prophylaxis and was this carried out? Was the antibiotic used appropriate? Was the timing of the first injection optimal? Was the total duration of the treatment correct? Was the dose correct?

RESULTS

The overall compliance with recommendations was significantly improved during the third period (P = 0.0002). This improvement was particularly marked for antimicrobial prophylaxis duration.

CONCLUSION

It seems that sequential surveillance of antimicrobial prophylaxis, including numerous surgical teams, could considerably improve the practices, if it was associated to informations that allowed physicians to appropriate the procedures.

Guidelines and management of mild hypertensive conditions in pregnancy in rural general practices in Scotland: issues of appropriateness and access

OBJECTIVES

To assess the diagnosis and management of mild non-proteinuric hypertension in pregnancy in rural general practices against guideline recommendations.

DESIGN

Postal survey and telephone interview.

SETTING

All 174 designated rural general practices in Scotland.

SAMPLE

171 GPs and 158 midwives responsible for antenatal care stratified by distance from a specialist maternity hospital.

MAIN OUTCOME MEASURES

Accuracy of diagnosis and appropriateness of management compared with guideline.

RESULTS

At least one respondent replied for 91% (158/174) of rural practices. Response rates were 68% (117/170) for GPs and 77% (121/158) for midwives. Both GP and midwife replied for 46% (80/174) of practices. Most GPs (80%, 87/109) and midwives (63%, 71/113) overdiagnosed the scenario. Intended management was therefore most often referral or admission to specialist hospital (59%, 132/224), both courses of action beyond guideline recommendations. There was an association between distance of practice from specialist maternity hospital and professionals' report of intended referral or admission. Explanatory factors from telephone interviews included a poor knowledge base, cautious risk assessment, and perceived inflexibility of guidelines for remote situations.

CONCLUSIONS

There is a lack of accuracy in the diagnosis of a common antenatal problem and intended management is consistent with overdiagnosis. The results suggest that women in rural settings may experience more antenatal referrals and admissions than are clinically appropriate according to the guidelines. At a time of increasing centralisation of maternity services, this could increase inappropriate referrals and increase costs to service and patients. Quality of care may be improved by developing consensual local guidelines with rural maternity care professionals and support maintained skills and confidence in decision making.

The quantity and quality of clinical practice guidelines for the management of depression in primary care in the UK

BACKGROUND

Despite research evidence that guidelines can improve patient care, concerns remain over their cost-effectiveness. This is particularly so when there is a proliferation of guidelines for the same condition. Faced with differing recommendations, users will wish to make informed decisions on which guideline to follow. In creating a guideline appraisal instrument we have assessed guidelines developed in the United Kingdom (UK) for the management of a range of disorders including depression in primary care.

AIM

To identify the number of UK clinical guidelines for the management of depression in primary care and to describe their quality and clinical content.

METHOD

A survey was undertaken to identify all depression guidelines developed in the UK between January 1991 and January 1996. All guidelines produced by national organizations and a random sample of local guidelines were appraised using a validated instrument by six assessors: a national expert in the disease area, a general practitioner, a public health physician, a hospital consultant, a nurse specializing in the disease area, and a researcher on guideline methodology. The clinical content of each guideline was then assessed by one of the researchers (RB) according to a defined framework.

RESULTS

Forty-five depression guidelines were identified. While there was a considerable range in the quality of the six national and three local guidelines appraised, at a group level their performance was similar to guidelines for other diseases. Clinical recommendations tended to reflect the joint consensus statement produced by the Royal College of General Practitioners and Royal College of Psychiatrists in 1992. The most obvious difference was in the style in which the guidelines were written and presented.

CONCLUSION

A 'national template' was the starting place for most guidelines. Steps need to be taken to ensure that these templates are based on the best possible research evidence and professional opinion. Local clinicians should concentrate on effective dissemination and implementation strategies, rather than creating new guidelines.

Beyond guidelines: promoting clinical change in the real world

There is widespread recognition that simply publishing research findings is not enough to ensure that they are carried into clinical practice. One response to this has been the burgeoning "guidelines movement" of recent years, which has now reached the stage of generating guidelines for the production of guidelines. Argues that guidelines, and other forms of intervention to change clinical practice in an evidence-based direction, will succeed only to the extent that they engage actively with the real world of clinical decision making. This world is more complex than guidelines writers acknowledge, and includes economic, administrative, professional and personal incentives as well as those provided by research evidence. Engaging with this real world may be difficult, but it opens up new possibilities for understanding how clinicians act and how evidence may be used to inform clinical practice. Such possibilities include social influences, educational outreach, providing information to patients, negotiating local coalitions on specific issues and changing the administrative environment.