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

Doctors' Knowledge of Hypertension Guidelines Recommendations Reflected in Their Practice

Aim

To evaluate doctors' knowledge, attitude, and practices and predictors of adherence to Malaysian hypertension guidelines (CPG 2008).

Methods

Twenty-six doctors involved in hypertension management at Penang General Hospital were enrolled in a cross-sectional study. Doctors' knowledge and attitudes towards guidelines were evaluated through a self-administered questionnaire. Their practices were evaluated by noting their prescriptions written to 520 established hypertensive outpatients (20 prescriptions/doctor). SPSS 17 was used for data analysis.

Results

Nineteen doctors (73.07%) had adequate knowledge of guidelines. Specialists and consultants had significantly better knowledge about guidelines' recommendations. Doctors were positive towards guidelines with mean attitude score of 23.15 ± 1.34 points on a 30-point scale. The median number of guidelines compliant prescriptions was 13 (range 5–20). Statistically significant correlation (r_s = 0.635, P < 0.001) was observed between doctors' knowledge and practice scores. A total of 349 (67.1%) prescriptions written were guidelines compliant. In multivariate analysis hypertension clinic (OR = 0.398, P = 0.008), left ventricular hypertrophy (OR = 0.091, P = 0.001) and heart failure (OR = 1.923, P = 0.039) were significantly associated with guidelines adherence.

Conclusion

Doctors' knowledge of guidelines is reflected in their practice. The gap between guidelines recommendations and practice was seen in the pharmacotherapy of uncomplicated hypertension and hypertension with left ventricular hypertrophy, renal disease, and diabetes mellitus.

Documentation of preventive screening interventions by general practitioners: a retrospective chart audit

Background

Screening and early diagnosis has been shown to reduce the morbidity and mortality associated with certain conditions such as cervical cancer. The role of general practitioners in promoting primary prevention of diseases is particularly important given that they have frequent contact with a large proportion of the population. This study assessed the extent to which general practitioners documented recommended preventive screening interventions among eligible patients.

Methods

We used a retrospective chart audit to assess patient visits to primary care clinics in Calgary, Canada from 2002-2004. We included fee for service physicians who practiced ≥ 2 days per week at their current location and excluded those whose primary practice was at walk-in clinics, community health centers, hospitals or emergency rooms. We included charts of patients who during the study period were age 35 years or older and had at least 2 visits to a clinic. We randomly selected and reviewed charts (N = 600) from 12 primary care clinics and abstracted information on 6 conditions recommended for preventive screening. Opportunities for preventive screening were determined based on recommendations of the Canadian Task Force on Preventive Health Care, the American College of Physicians, and the Canadian Cancer Society. Our main outcome measures included cancer screening (mammography and pap smears), immunization (influenza and pneumococcal), and risk factor assessment (cholesterol measurement and smoking cessation consultation).

Results

Patient visits to GP clinics present opportunities for preventive screening. However, we found that documentation of interventions was low, ranging from 40.3% (cholesterol measurement) to 0.9% (pneumococcal vaccination) within 1 year, and from 67.4% to 1.8% within the prior 3 years.

Conclusions

Documentation of preventive screening interventions by general practitioners was relatively low compared to the number of patients eligible for preventive screening. Some physicians opt to screen for PSA and DRE which is not recommended by the Canadian Task Force on Preventive HealthCare.

A follow-up study of the occurrence and consequences of HbA1c measurements in an unselected cohort of non-pharmacologically treated patients with Type 2 diabetes

OBJECTIVES

To describe the occurrence of HbA1c measurements among non-pharmacologically treated diabetes patients, and to evaluate whether poor blood glucose regulation (HbA1c >8%) prompted intensification of treatment.

METHOD

Data from the National Health Service Registry, the Regional Laboratory Database and the Danish National Hospital Registry were collected from 2002 to 2004 to identify and describe all Type 2 diabetic patients above 40 years of age in a background population of nearly 660,000 citizens in Aarhus County, corresponding to 12% of the total Danish population.

RESULTS

A total of 1989 had at least one HbA1c measurement, whereas 484 (20%) had no HbA1c measurement at all in 2003. Most patients had an HbA1c of less than 8%, and for 820 (41%) HbA1c was less than 6.5%, but for 316 (16%) patients, the first HbA1c measurement in 2003 was above 8%. After 6 months, patients with HbA1c above 8% had a higher probability of initiating pharmacological treatment (M; 0.64; 95% CI 0.58-0.70) (F; 0.68; 95% CI 0.58-0.77) than patients with HbA1c below 8% (M; 0.12; 95% CI 0.10-0.14) (F; 0.11; 95% CI 0.09-0.14).

CONCLUSION

This study indicates that poor blood glucose regulation (HbA1c >8%) prompted a shift from non-pharmacological treatment to pharmacological treatment for most patients. However, a substantial group of patients are either not monitored on a regular basis or, if monitored, their elevated measurements of HbA1c do not prompt initiation of pharmacological treatment.

[Representations of clinical practice guidelines by general practitioners]

The objective of this study is to understand the representations of general practitioners in regards to clinical practice guidelines. Two general practitioners samples have been studied according to two analytical methods: the method of scenarios, sent by e-mail to doctors belonging to a network, and a round table gathering volunteers having answered the scenario and drawn lots. 279 answers were received from 252 men and 27 women (response rate of 80%); eleven doctors (4 women) participated in the round table. Results analysis shows that the credibility of the scenario is judged as very good. Only 39% of the referees estimated that practice guidelines are little useful. The ideal type of answers was established. Five themes appeared from the debate, the main two being the elaboration of the guidelines and the measured opposition between medicine applied to individuals and epidemiology. The majority of the physicians considered clinical guidelines as a trump card, at the same moment as a tool and as an instigation, but found them difficult to hold and asked for their improvement.

Inadequate treatment of dyslipidemia in people with type 2 diabetes: quality assessment of diabetes care in a Danish County

OBJECTIVE

This study aims to describe the routine monitoring of lipids and the use of lipid-lowering medicine in people with type 2 diabetes in the period 2000-2002.

MATERIAL AND METHODS

Data from the National Health Service Registry, the Regional laboratory database and the Danish National Hospital Registry have been used for identification and description of known diabetes in a background population of 649,177 citizens in the County of Aarhus, corresponding to 12% of the total Danish population. All data were collected for the period 1 January 2000 to 31 December 2002.

RESULTS

A total of 14,644 people with type 2 diabetes were identified, 52% of whom were men. The mean age was 64 years and the mean duration of diabetes was 7 years. A total of 61% had a minimum of one measurement of total cholesterol in 2000 compared with 64% in 2002. Some 71% of the patients in 2000 compared with 66% in 2002 had a total cholesterol concentration above 5.0 mmol/l. The proportion of people with type 2 diabetes treated with a lipid-lowering drug increased from 15% in 2000 to 24% in 2002. For those who were treated with lipid-lowering medication 33% in 2000 and 42% in 2002 reached currently recommended targets of total cholesterol concentrations.

CONCLUSIONS

The results of this study provide a realistic picture of the monitoring of cholesterol as part of diabetes care and found a tendency to increased adherence to guidelines. Even so, it seems as if more patients with diabetes could benefit from treatment with lipid-lowering medication.

Teleconferenced educational detailing: diabetes education for primary care physicians

INTRODUCTION

Formal didactic continuing medical education (CME) is relatively ineffective for changing physician behaviour. Diabetes mellitus is an increasingly prevalent disease, and interventions to improve adherence to clinical practice guidelines (CPGs) are needed.

METHODS

A stratified, cluster-randomized, controlled trial design was used to evaluate the effects of a teleconferenced educational detailing (TED) CME on glycemic control (hemoglobin [Hb] A1c) and family physician adherence to national diabetes guidelines. TED employed sequential, small-group, case-based education using CPGs delivered by a diabetes specialist. Medical record audit data from baseline through the end of a 12-month postintervention period were compared for the control and intervention groups. Satisfaction with the intervention was evaluated.

RESULTS

Sixty-one physicians provided 660 medical records. The intervention did not affect mean Hb A1c levels but did significantly (p = .04) alter the distribution of patients by category of glycemic control, with fewer in the intervention group in inadequate control (15.8% versus 23.9%). More patients took insulin (alone or with oral agents) in the intervention group (21.2% versus 12.0%, p = .03), and more took oral agents only in the control group (89.0% versus 82.9%, p = .005). More patients in the intervention group had documentation of body mass index (7.8% versus 1.9%, p < .02), eye exam (12.1% versus 5.1%, p = .02), and treatment plan (43.5% versus 23.6%, p = .01) and used a flow sheet (14.6% versus 7.7%, p < .03). Although there was general satisfaction with the teleconferencing format, specialist educators found the format more challenging than the family physicians.

DISCUSSION

CME delivered by teleconference was feasible, well attended, well received by participants, and improved some key diabetes management practices and outcomes.

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.

Clinicians' attitudes to clinical practice guidelines: a systematic review

OBJECTIVE

To systematically review surveys of clinicians' attitudes to clinical practice guidelines.

DATA SOURCES

MEDLINE, HealthStar, Embase and CINAHL were searched electronically for English-only surveys published from 1990 to 2000.

STUDY SELECTION

We included surveys with responses to one or more of seven propositions (see below). Studies were excluded if they had fewer than 100 respondents or if the response rate was less than 60%.

RESULTS

Thirty studies included responses to one or more of the seven items, giving a total of 11 611 responses. The response rate for the included studies was 72% (95% confidence interval [CI], 69%-75%). Clinicians agreed that guidelines were helpful sources of advice (weighted mean, 75%; 66%-83%), good educational tools (71%; 63%-79%) and intended to improve quality (70%; 60%-80%). However, clinicians also considered guidelines impractical and too rigid to apply to individual patients (30%; 23%-36%), that they reduced physician autonomy and oversimplified medicine (34%; 22%-47%), would increase litigation (41%; 32%-49%) and were intended to cut healthcare costs (52.8%; 39%-66%).

CONCLUSIONS

Surveys of healthcare providers consistently report high satisfaction with clinical practice guidelines and a belief that they will improve quality, but there are concerns about the practicality of guidelines, their role in cost-cutting and their potential for increasing litigation.

Do guidelines matter? A population-based study of diabetes drug use during 20 years

OBJECTIVE

To analyse diabetes drug use in a defined population during 20 years in relation to recommendations in published guidelines.

DESIGN

From the Tierp Study Database, all medical records for diabetes patients at the primary health care centre in Tierp municipality and all prescriptions for diabetes drugs at the local pharmacies during the period 1975-1994 were collected. Data for 2125 persons were obtained, generating 13,190 person-years of observation.

SETTING

Tierp primary health care district.

MAIN OUTCOME MEASURES

Diabetes treatment.

RESULTS

The annual prevalence of diabetes mellitus increased from 2.8% (565 patients) to 3.8% (734 patients). When guidelines emphasised diet treatment, treatment with diet only increased and oral pharmacological treatment decreased. When guidelines emphasised better glycaemic control, diet only decreased and biguanide treatment increased, and when guidelines emphasised vigorous glycaemic control, treatment with diet only decreased further and sulphonylurea and insulin use increased. The substantial age and sex differences in antidiabetic drug use at the beginning of the period were partly reduced over time.

CONCLUSIONS

The considerable changes in antidiabetic drug use during the study period coincided with changes in the guidelines issued. The age and sex differences in drug use became less pronounced towards the end of the period.

Awareness and use of the Ottawa ankle and knee rules in 5 countries: can publication alone be enough to change practice?

STUDY OBJECTIVES

We evaluate the international diffusion of the Ottawa Ankle and Knee Rules and determine emergency physicians' attitudes toward clinical decision rules in general.

METHODS

We conducted a cross-sectional, self-administered mail survey of random samples of 500 members each of the American College of Emergency Physicians, Canadian Association of Emergency Physicians, British Association for Accident and Emergency Medicine, Spanish Society for Emergency Medicine, and all members (n=1,350) of the French Speaking Society of Emergency Physicians, France. Main outcome measures were awareness of the Ottawa Ankle and Knee Rules, reported use of these rules, and attitudes toward clinical decision rules in general.

RESULTS

A total of 1,769 (57%) emergency physicians responded, with country-specific response rates between 49% (United States and France) and 79% (Canada). More than 69% of physicians in all countries, except Spain, were aware of the Ottawa Ankle Rules. Use of the Ottawa Ankle Rules differed by country with more than 70% of all responding Canadian and United Kingdom physicians reporting frequent use of the rules compared with fewer than one third of US, French, and Spanish physicians. The Ottawa Knee Rule was less well known and less used by physicians in all countries. Most physicians in all countries viewed decision rules as intended to improve the quality of health care (>78%), a convenient source of advice (>67%), and good educational tools (>61%). Of all physicians, those from the United States held the least positive attitudes toward decision rules.

CONCLUSION

This constitutes the largest international survey of emergency physicians' attitudes toward and use of clinical decision rules. Striking differences were apparent among countries with regard to knowledge and use of decision rules. Despite similar awareness in the United States, Canada, and the United Kingdom, US physicians appeared much less likely to use the Ottawa Ankle Rules. Future research should investigate factors leading to differences in rates of diffusion among countries and address strategies to enhance dissemination and implementation of such rules in the emergency department.