Towards efficient guidelines: how to monitor guideline use in primary care

Improving acute medical management: Junior Doctor Emergency Prescription Cards

Doctors commencing Foundation Year (FY) training face many stresses and challenges. FY doctors are often the first point of contact for acutely unwell and deteriorating patients. Trust guidelines are used to aid acute medical management. Accessing guidelines is often fraught with barriers. Evidence suggests aide-memoire cards can provide easier access to guidelines and management pathways.

We aimed to improve prescribing accuracy and efficiency of FY doctors for acute medical conditions within Gloucestershire trust by improving access to and usability of trust guidelines.

Questionnaires were distributed to FY doctors to identify acute medical conditions to include on the emergency prescription cards (EPCs). Two small double-sided cards were created containing bullet pointed trust guidelines for: hyper/hypokalaemia, status epilepticus, diabetic emergencies, arrhythmias, myocardial infarction, acute asthma, pulmonary oedema, anaphylaxis and a ward-round checklist. Feedback was used to improve EPCs prior to distribution. Pre (N=53) and post-intervention (N=46) written questionnaires were completed by FY doctors. These assessed acute clinical management including use of guidance, confidence in management, speed of prescribing and EPC “usability”. To assess prescribing accuracy, prescriptions for acute medical conditions were reviewed pre (N=8) and post-intervention (N=12).

The EPCs were well received (80% quite/very useful) and found “easy to use” (83%). The introduction of EPCs increased guidance use (pre-intervention 58.8%, post-intervention 71.7%), increased confidence (pre-intervention 79%, post-intervention 89%) and significantly improved prescribing speed (p=0.05). There was a significant correlation with confidence and prescribing speed (p = 0.023). The accuracy of prescribed doses improved (pre-intervention 62.5%, post-intervention 87.5% accurate) as did details regarding route / additional required information (pre-intervention 75%, post-intervention 97.7%).

The EPCs support the management of unwell patients, are relevant to the workload of modern doctors practice and may improve patient care. This improvement measure could be applied to other NHS trusts and medical specialties.

Experimenting clinical pathways in general practice: a focus group investigation with italian general practitioners

Background

Clinical governance is considered crucial in primary care. Since 2005, clinical pathways have been experimentally implemented at the Local Health Authority of Monza Brianza (ASLMB), Italy, to develop general practitioners’ (GPs) care of patients affected by some chronic diseases. The experimentation was aimed at introducing clinical governance in primary care, increasing GPs’ involvement in the care of their patients, and improving both patients’ and professionals’ satisfaction. In the period 2005-2006, 12% of the 763 employed GPs in the ASLMB were involved in the experiment, while this percentage increased to 15-20% in 2007-2008.

Design and Methods

Twenty-four GPs were purposively sampled, randomly divided into two groups and asked to participate in focus groups (FGs) held in 2008, aimed at evaluating their perception of the experiment. The FGs were audio-recorded, dialogues were typed out and undergone to a thematic analysis, according to the Interpretative Phenomenological Approach.

Results

Four major themes emerged: i) clinical pathways can result in GPs working in a more efficient and effective fashion; ii) they can assure higher levels of both patient and professional satisfaction, since they sustain a caring approach and strengthen the GPs’ role; iii) nevertheless, clinical pathways increase the bureaucratic workload and problems can arise in relationships among GPs and the LHA; iv) the implementation of clinical pathways can be improved, especially by reducing bureaucracy and by assuring their continuity.

Conclusions

Managerial aspects should be considered with care in order to experimentally introduce clinical pathways in general practice, and continuity of the experimentation should be guaranteed to improve GPs’ adherence and commitment.

Acknowledgments

the Authors thank Dr. AP. Cantù and Dr D. Cereda who participated in the two focus groups as observers.

Effectiveness of an implementation strategy for a breastfeeding guideline in Primary Care: cluster randomised trial

Background

The protection and promotion of breastfeeding is considered a priority in Europe where only 22% of infants less than 6 months old are exclusively breastfed. In Spain this percentage reaches 24.8% but in our city it falls to 18.26%. Various studies emphasise that the improvement of these results should be based upon the training of health professionals. Following the recommendations of a breastfeeding guide can modify the practice of health professionals and improve results with respect to exclusively or predominatly breastfed children at 6 months of age.

Method/Design

This study involves a community based cluster randomized trial in primary healthcare centres in Leganés (Madrid, Spain). The project aims to determine whether the use of an implementation strategy (including training session, information distribution, opinion leader) of a breastfeeding guideline in primary care is more effective than usual diffusion.

The number of patients required will be 240 (120 in each arm). It will be included all the mothers of infants born during the study period (6 months) who come to the health centre on the first visit of the child care programme and who give their consent to participate. The main outcome variable is the exclusive o predominant breastfeeding at 6 moths of age..

Main effectiveness will be analyzed by comparing the percentage of infants with exclusive or predominant breastfeeding at 6 months between the intervention group and the control group. All statistical tests will be performed with intention to treat. Logistic regression with random effects will be used to adjust for prognostic factors. Confounding factors or factors that might alter the effect recorded will be taken into account in this analysis.

Discussion

Strategies need to be found which facilitate the giving of effective advice on breastfeeding by professionals and which provide support to women during the breastfeeding period. By applying the guide's recommendations, clinical variability can be reduced and the care received by patients can be improved.

Trial registration

The trial was registered with ClinicalTrials.gov, number NCT01474096

Effectiveness of a clinical practice guideline implementation strategy for patients with anxiety disorders in primary care: cluster randomized trial

BACKGROUND

Anxiety is a common mental health problem seen in primary care. However, its management in clinical practice varies greatly. Clinical practice guidelines (CPGs) have the potential to reduce variations and improve the care received by patients by promoting interventions of proven benefit. However, uptake and adherence to their recommendations can be low.

METHOD/DESIGN

This study involves a community based on cluster randomized trial in primary healthcare centres in the Madrid Region (Spain). The project aims to determine whether the use of implementation strategy (including training session, information, opinion leader, reminders, audit, and feed-back) of CPG for patients with anxiety disorders in primary care is more effective than usual diffusion. The number of patients required is 296 (148 in each arm), all older than 18 years and diagnosed with generalized anxiety disorder, panic disorder, and panic attacks by the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). They are chosen by consecutive sampling. The main outcome variable is the change in two or more points into Goldberg anxiety scale at six and twelve months. Secondary outcome variables include quality of life (EuroQol 5D), and degree of compliance with the CPG recommendations on treatment, information, and referrals to mental health services. Main effectiveness will be analyzed by comparing the patients percentage improvement on the Goldberg scale between the intervention group and the control group. Logistic regression with random effects will be used to adjust for prognostic factors. Confounding factors or factors that might alter the effect recorded will be taken into account in this analysis.

DISCUSSION

There is a need to identify effective implementation strategies for CPG for the management of anxiety disorders present in primary care. Ensuring the appropriate uptake of guideline recommendations can reduce clinical variation and improve the care patients receive.

TRIAL REGISTRATION

ISRCTN: ISRCTN83365316.

[Effect of the implementation of a program to improve referrals by primary care on appropriateness and wait times in endoscopic examinations]

INTRODUCTION

Within a program to improve referrals by primary care (PC) in Ourense (Spain), we implemented practice guidelines on dyspepsia and rectal bleeding. Our aim was to evaluate the reasons for referral to endoscopy, the appropriateness of these referrals, and wait times.

MATERIAL AND METHODS

We performed a retrospective cohort study in the Ourense health area between February 2009 and January 2010. The endoscopies performed with the indications of dyspepsia and rectal bleeding requested directly from PC were compared with those referred initially to specialist care (SC). The reasons for the referral, the priority of the endoscopy, compliance with the protocol, endoscopic finding and the wait time from referral were gathered.

RESULTS

During the period analyzed, 158 upper gastrointestinal endoscopies (SC: 121; PC: 37) and 243 colonoscopies (SC: 193; PC: 50) were performed with the indications of dyspepsia and rectal bleeding. Among endoscopies, 34.5% and 77.7% were requested with high priority from PC and SC, respectively (p<0.001). The criteria for referral were met in 86.5% of upper gastrointestinal endoscopies and in 82% of colonoscopies requested from PC. No differences were found in endoscopic findings. The median wait time from referral was lower in upper gastrointestinal endoscopy (PC: 105±5.5 days, SC: 174±17.8 days; p: 0.003) and colonoscopies (PC: 101±11.8 days, SC: 187±9.6 days; p<0.001) referred from PC.

CONCLUSIONS

The use of the program for improved referrals by PC reduces wait times. The examinations requested complied with the indications.

Guidelines in dermatology--quo vadis?: Facts and controversies

Since their introduction in 1980s, medical guidelines have become a milestone in the modern medical practice and science. Being a key feature of modern evidence-based medicine, guidelines offer the opportunity for unification and standardization of diagnostic procedures, their use guarantees the equal access of patients to medical service, and they represent a scaffold for inexperienced physicians. The implementation of guidelines also can serve as a basis in malpractice issues and can contribute to the formation of national and international health care policies. In past decades, the process of development, update, and practical application of clinical guidelines has been seriously improved; however, certain limitations still exist, namely cost-effectiveness issues, editorial independence, applicability, accessibility, and external validity. This contribution discusses the advantages and the drawbacks in the use and the development of medical guidelines, emphasizing future perspectives and challenges in the development of clinical guidelines.

Do guidelines create uniformity in medical practice?

This article aimed to test the general hypothesis that guidelines create uniformity, or reduce variation, in medical practice. Medical practice variation has policy interest and is one of the reasons for developing guidelines. The development and implementation of guidelines was considered in the broader context of processes of rationalization. We focused on the influence of voluntary guidelines developed by the professional organization for family physicians in the Netherlands on variation in drug prescription. Data were used from the First and Second Dutch National Survey of General Practice (DNSGP1 and DNSGP2), collected in 1987 and 2001 respectively. DNSGP1 consisted of 103 practices and 161 GPs serving 335.000 patients. DNSGP2 consisted of 104 practices and 195 GPs serving 390.000 patients. Two groups of diagnoses were created, one containing all diagnoses for which guidelines were introduced and one containing all other diagnoses. For both groups a measure of concentration, Herfindahl-Hirschman Index (HHI), was used to represent variation. This measure of concentration was compared between both groups using multilevel analysis. Results showed that although there was an overall increase in variation (a significantly lower HHI) in prescription, the increase was less in the cases of diagnoses for which guidelines were introduced. Guidelines, primarily, had an effect on variations in single-handed practices. The overall conclusion is that the introduction of guidelines, although it probably tempered the increase in variation, did not reduce variation.

Diagnostic imaging practice guidelines for musculoskeletal complaints in adults--an evidence-based approach: introduction

PURPOSE

Imaging technology can improve patient outcomes by allowing greater precision in diagnosing and treating patients. However, there is evidence that overuse, underuse, and misuse of imaging services occur. The purpose of this project was to develop evidence-based diagnostic imaging practice guidelines for musculoskeletal complaints for use by doctors of chiropractic and other primary health care professionals.

METHODS

An electronic search of the English and French language literature (phase 1) was conducted on several databases. Cross references, and references provided by clinicians, were also used. Independent assessment of the quality of the citations used to support recommendations in the guidelines was performed using the QUADAS, the AGREE,and the SPREAD evaluation tools. A first draft of a diagnostic imaging practice guideline was produced, using the European Commission's Referral Guidelines for Imaging document as a template. Results were sent to 12 chiropractic specialists for a first external review. A modified Delphi process, including 149 international experts, was used to generate consensus on recommendations for diagnostic imaging studies. The reliability of proposed recommendations was further tested on field chiropractors and on a group of specialists both in chiropractic and in medicine in both Canada and the United States. All recommendations were graded according to the strength of the evidence.

RESULTS

The research procedure resulted in the recommendations for diagnostic imaging guidelines of adult extremity and spine disorders supported by more than 685 primary and secondary citations. High levels of agreement among Delphi panelists were reached for all proposed recommendations. Comments received by specialists were generally very favorable and reflected high levels of agreement with the proposed recommendations, perceived ease of use of guidelines, and implementation feasibility.

CONCLUSIONS

These evidence-based diagnostic imaging practice guidelines are intended to assist chiropractors and other primary care providers in decision making on the appropriate use of diagnostic imaging for specific clinical presentations. In all cases, the guidelines are intended to be used in conjunction with sound clinical judgment and experience. Application of these guidelines should help avoid unnecessary radiographs, increase examination precision,and decrease health care costs without compromising the quality of care. All guidelines are documents to be refined and modified regularly with new information and experience.

Does a joint development and dissemination of multidisciplinary guidelines improve prescribing behaviour: a pre/post study with concurrent control group and a randomised trial

BACKGROUND

It is difficult to keep control over prescribing behaviour in general practices. The purpose of this study was to assess the effects of a dissemination strategy of multidisciplinary guidelines on the volume of drug prescribing.

METHODS

The study included two designs, a quasi-experimental pre/post study with concurrent control group and a random sample of GPs within the intervention group. The intervention area with 53 GPs was compared with a control group of 54 randomly selected GPs in the south and centre of the Netherlands. Additionally, a randomisation was executed in the intervention group to create two arms with 27 GPs who were more intensively involved in the development of the guideline and 26 GPs in the control group. A multidisciplinary committee developed prescription guidelines. Subsequently these guidelines were disseminated to all GPs in the intervention region. Additional effects were studied in the subgroup trial in which GPs were invited to be more intensively involved in the guideline development procedure. The guidelines contained 14 recommendations on antibiotics, asthma/COPD drugs and cholesterol drugs. The main outcome measures were prescription data of a three-year period (one year before and 2 years after guideline dissemination) and proportion of change according to recommendations.

RESULTS

Significant short-term improvements were seen for one recommendation: mupirocin. Long-term changes were found for cholesterol drug prescriptions. No additional changes were seen for the randomised controlled study in the subgroup. GPs did not take up the invitation for involvement.

CONCLUSION

Disseminating multidisciplinary guidelines that were developed within a region, has no clear effect on prescribing behaviour even though GPs and specialists were involved more intensively in their development. Apparently, more effort is needed to bring about change.

Assessing adherence to the evidence base in the management of poststroke dysphagia

OBJECTIVE

To evaluate the reliability and responsiveness to change of an audit tool to assess adherence to evidence of effectiveness in the speech and language therapy (SLT) management of poststroke dysphagia.

DESIGN

The tool was used to review SLT practice as part of a randomized study of different education strategies. Medical records were audited before and after delivery of the trial intervention.

SETTING

Seventeen SLT departments in the north-west of England participated in the study.

SUBJECTS

The assessment tool was used to assess the medical records of 753 patients before and 717 patients after delivery of the trial intervention across the 17 departments. A target of 10 records per department per month was sought, using systematic sampling with a random start.

ANALYSIS

Inter- and intra-rater reliability were explored, together with the tool's internal consistency and responsiveness to change.

RESULTS

The assessment tool had high face validity, although internal consistency was low (ra = 0.37). Composite scores on the tool were however responsive to differences between SLT departments. Both inter- and intra-rater reliability ranged from 'substantial' to 'near perfect' across all items.

CONCLUSIONS

The audit tool has high face validity and measurement reliability. The use of a composite adherence score should, however, proceed with caution as internal consistency is low.

Implementing clinical protocols in oncology: quality gaps and the learning curve phenomenon

BACKGROUND

The quality improvement effort in clinical practice has focused mostly on 'performance quality', i.e. on the development of comprehensive, evidence-based guidelines. This study aimed to assess the 'conformance quality', i.e. the extent to which guidelines once developed are correctly and consistently applied. It also aimed to assess the existence of quality gaps in the treatment of certain patient segments as defined by age or gender and to investigate methods to improve overall conformance quality.

METHODS

A retrospective audit of clinical practice in a well-defined oncology setting was undertaken and the results compared to those obtained from prospectively applying an internally developed clinical protocol in the same setting and using specific tools to increase conformance quality.

RESULTS

All indicators showed improvement after the implementation of the protocol that in many cases reached statistical significance, while in the entire cohort advanced age was associated (although not significantly) with sub-optimal delivery of care. A 'learning curve' phenomenon in the implementation of quality initiatives was detected, with all indicators improving substantially in the second part of the prospective study.

CONCLUSIONS

Clinicians should pay separate attention to the implementation of chosen protocols and employ specific tools to increase conformance quality in patient care.