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PubMed2000

Effects of job characteristics, team climate, and attitudes towards clinical guidelines.

The aim of this study was to form and test a model of the antecedents and possible moderators of the use of clinical guidelines among healthcare professionals. A postal questionnaire survey of all workers in six health centres around Finland. was carried out in April 1996. The health centres were selected to represent all different areas of Finland. A total of 748 (65.5%) of the healthcare workers completed and returned the questionnaire. Of the respondents 95% were women, 16% physicians or dentists, 31% registered nurses, and 27% practical nurses. It was hypothesized that besides positive attitudes towards guidelines, job characteristics and team climate affect the use of guidelines. Three alternative models of possible main and moderating effects of attitudes, job characteristics, and team climate were formed and tested. These models were tested using hierarchical regression analysis and structural equation modelling (LISREL8). All of the hypothesized main effects and the moderating effect of job characteristics between attitudes towards and the use of guidelines were supported. According to our results important factors behind the general positive or negative attitudes towards guidelines are the usefulness, reliability, practicality, and availability of the guidelines. Also, the overall individual, team, and organizational competence to follow the procedures recommended, seemed to be vital. Moreover, those whose job motivation potential was high were more ready to use clinical guidelines even when their attitudes towards guidelines were the same.

Attitude of Health Personnel↗

PubMed2004

The role of guidelines and the patient's life-style in GPs' management of hypercholesterolaemia.

BACKGROUND: Recent Swedish and joint European guidelines on hyperlipidaemia stress the high coronary risk for patients with already established arterio-sclerotic disease (secondary prevention) or diabetes. For the remaining group, calculation of the ten-year risk for coronary events using the Framingham equation is suggested. There is evidence that use of and adherence to guidelines is incomplete and that tools for risk estimations are seldom used. Intuitive risk estimates are difficult and systematically biased. The purpose of the study was to examine how GPs use knowledge of guidelines in their decisions to recommend or not recommend a cholesterol-lowering drug and the reasons for their decisions. METHODS: Twenty GPs were exposed to six case vignettes presented on a computer. In the course of six screens, successively more information was added to the case. The doctors were instructed to think aloud while processing the cases (Think-Aloud Protocols) and finally to decide for or against drug treatment. After the six cases they were asked to describe how they usually reason when they meet patients with high cholesterol values (Free-Report Protocols). The two sets of protocols were coded for cause-effect relations that were supposed to reflect the doctors' knowledge of guidelines. The Think-Aloud Protocols were also searched for reasons for the decisions to prescribe or not to prescribe. RESULTS: According to the protocols, the GPs were well aware of the importance of previous coronary heart disease and diabetes in their decisions. On the other hand, only a few doctors mentioned other arterio-sclerotic diseases like stroke and peripheral artery disease as variables affecting their decisions. There were several instances when the doctors' decisions apparently deviated from their knowledge of the guidelines. The arguments for the decisions in these cases often concerned aspects of the patient's life-style like smoking or overweight- either as risk-increasing factors or as alternative strategies for intervention. CONCLUSIONS: Coding verbal protocols for knowledge and for decision arguments seems to be a valuable tool for increasing our understanding of how guidelines are used in the on treatment of hypercholesterolaemia. By analysing arguments for treatment decisions it was often possible to understand why departures from the guidelines were made. While the need for decision support is obvious, the current guidelines may be too simple in some respects.

Adult↗

PubMed2006

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.

Adult↗

PubMed2006

Embedded guideline information without patient specificity in a commercial emergency department computerized order-entry system.

BACKGROUND: Clinical practice guidelines and computerized provider order entry (CPOE) have potential for improving clinical care. Questions remain about feasibility and effectiveness of CPOE in the emergency department (ED). However, successful implementations in other settings typically incorporate decision support functions that are lacking in many commercially available ED information systems. OBJECTIVES: To compare acute coronary syndrome (ACS) guideline compliance before and after implementation of a locally implemented ACS guideline, first on paper and then in a commercially available ED information system without patient-specific clinical decision support. METHODS: Clinical data were abstracted retrospectively on patients seen before and after introduction of paper and, subsequently, CPOE versions of ACS guideline-based order-sets. Order-set use was determined. Risk category assignments were made retrospectively using guideline criteria and compliance with the guideline regarding beta-blockers, heparin, and aspirin was determined. Association between order-set use and compliance was determined. RESULTS: The authors found increasing use of order-sets over the period of study. However, there was poor association between the order-sets used and risk stratification category. Some association between ED beta-blocker use and use of CPOE order-sets was found, but there was no improvement in overall compliance with any of the guideline recommendations. CONCLUSIONS: Adherence to an ACS guideline did not improve with implementation of a commercial ED information system without provision for patient-specific decision support. This suggests that the lack of patient-specific decision-support functionality in most current ED information system products may hamper progress in the development of effective decision support.

Adrenergic beta-Antagonists↗

PubMed1998

Assuring the optimal use of serotonin antagonist antiemetics: the process for development and implementation of institutional antiemetic guidelines at Memorial Sloan-Kettering Cancer Center.

PURPOSE: The need to foster the appropriate and cost-effective use of serotonin-antagonist antiemetic drugs spurred the creation of guidelines. The process by which institution-wide guidelines at Sloan-Kettering were developed, implemented, assessed, and modified is described. METHODS: A multidisciplinary group working with disease-specific management teams assigned the emetic potential of chemotherapy programs to one of five categories. Antiemetic regimens, including a specified dose and schedule of a serotonin-antagonist and dexamethasone, were assigned to each emetic category. The information was collated by disease site and chemotherapy program into hospital-wide antiemetic regimen recommendations. Quality assessment was conducted initially and repeated each time the guidelines were modified. RESULTS: Patient surveys demonstrated a high level of satisfaction with emetic control, which was similar to reported results. Data from the latest survey showed zero emetic episodes in 93% and 87% of participants given moderate and highly emetogenic chemotherapy, respectively. Compliance with the guidelines, initially in 73%, has been improved using a standardized chemotherapy order "check box" labeled, "Antiemetics as per Guidelines." Antiemetic drug expenditures decreased from a projected $2.8 million to $1.3 million annually. CONCLUSION: The guidelines became an educational tool that ensured the delivery of optimal antiemetic therapy chosen by professionals with the greatest knowledge of both the particular chemotherapy regimen and cancer site. Implementation of the guidelines resulted in substantial savings while treating more patients. The guidelines were easily modified as new chemotherapeutic agents and antiemetic drugs became available.

Antiemetics↗

PubMed2004

Implementation of evidence-based tobacco use cessation guidelines in managed care organizations.

BACKGROUND: Although managed care organizations (MCOs) may be optimal settings for implementing tobacco use cessation clinical guidelines, such guidelines remain poorly implemented in many MCO settings. PURPOSE: We examined issues related to the implementation of guidelines in MCOs, to provide examples of studies that have addressed issues related to guideline implementation and to suggest ways behavioral medicine researchers can play a role in examining issues of how guidelines can be better implemented. METHODS: Surveys of clinical guideline implementation, studies from the Robert Wood Johnson Foundation addressing tobacco use cessation in a managed care database, selected to illustrate issues related to system-wide implementation. RESULTS: Surveys show that effective tobacco use cessation interventions remain underutilized in MCOs. A few studies have evaluated and shown the benefit of insurance coverage for tobacco use and dependence treatments, clinician reimbursement and leadership incentives, practice feedback, and leveraging administrative data to create tobacco use tracking systems. The studies also point to the need for large-scale, multidisciplinary, methodologically rigorous studies that allow one to isolate the effects of promising strategies as well as to explore synergistic effects as different system changes are combined. CONCLUSIONS: Tobacco use cessation guidelines need to be better implemented in MCOs. Behavioral medicine research needs to move beyond treatment efficacy and effectiveness studies to focus on rigorous evaluations of these and other strategies to enhance guideline implementation and dissemination.

Databases, Factual↗

PubMed2004

Implementation by Scottish otolaryngologists of the Scottish Intercollegiate Guidelines Network document Management of Sore Throats and the Indications for Tonsillectomy: four years on.

A postal survey was undertaken to assess otolaryngologists' awareness, implementation and perceived weaknesses of the Scottish Intercollegiate Guidelines Network (SIGN) clinical guideline for the Management of Sore Throat and Indications for Tonsillectomy. The reply rate was 77 per cent. There was high awareness of the guideline and while 84 per cent of the correspondents felt that they followed the guideline, or a guideline based on it, only 35 per cent were able to accurately recall the four main criteria recommended for listing for tonsillectomy. Twenty-five per cent of the surgeons were in departments that had ongoing implementation programmes for these guidelines but only 10 per cent of surgeons were in departments that had audited their compliance. The most common criticism of the guideline (22 per cent) was that it failed to consider the impact of the disease process on the patient's quality of life. Suggestions made to improve the guideline are included.

Guideline Adherence↗

PubMedDate not supplied

Improving guideline adherence for the diagnosis of ADHD in an ambulatory pediatric setting.

BACKGROUND: The American Academy of Pediatrics (AAP) has published clinical practice guidelines for the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD). However, implementation of guidelines has been notoriously difficult to achieve in the wider context of changing individual physicians' clinical practice. OBJECTIVE: Implement a formalized diagnostic protocol for ADHD and study whether this protocol improved adherence of pediatric residents and faculty to published guidelines for the diagnosis of ADHD. METHODS: Quasi-experimental retrospective record review of 63 pediatric patients evaluated for ADHD by pediatric residents and faculty in an outpatient pediatric clinic before (n = 25) and after (n = 38) implementation of a formal diagnostic process for ADHD. The key elements of the new diagnostic process include completion of a semistructured interview and mandatory rating scales for home and school. The published AAP guidelines include 1) documentation of Diagnostic and Statistical Manual for Mental Disorders (DSM) IV criteria; 2) evidence of core symptoms obtained directly from home and 3) from school; and 4) assessment for coexisting conditions. Adherence was assessed to each criterion individually (yes/no) and was summarized in a single score. RESULTS: Only 4% of clinicians and nurse practitioners diagnosing children in the before group adhered to all 4 AAP guidelines, compared to 82% in the after group (P < .001). Significant improvement was observed across each of the 4 criteria in the AAP guidelines. Moreover, the improvement in adherence to all 4 guidelines was noted for residents and faculty. CONCLUSION: A significant improvement in adherence to AAP guidelines was obtained for all providers through implementation of a structured diagnostic approach to ADHD.

Ambulatory Care↗

PubMed2004

Adherence to guidelines for community-acquired pneumonia: does it decrease cost of care?

Community-acquired pneumonia (CAP) is a common diagnosis and care of CAP is responsible for significant healthcare expenditures, the majority of which are for patients who require hospitalisation. Studies have shown that significant variation exists among institutions with respect to antibacterial costs and length of stay (LOS) for CAP. These variations do not appear to be associated with significant differences in patient outcomes. This information has stimulated the development of practice guidelines and critical pathways to optimise the care of patients with CAP. The central focus of guidelines is recommendations for antibacterial therapy; critical pathways include recommendations for therapy, but focus on the process of care for patients with CAP. Guidelines and critical pathways are time consuming to develop and their implementation requires significant institutional resources. Therefore, it is essential that they are shown to be effective, and there has been significant interest in determining if guidelines and pathways can improve the cost effectiveness of care. In the past several years, a number of studies have evaluated the impact of treatment consistent with guidelines on outcomes for patients with CAP. These studies have shown that antibacterial therapy that is consistent with guidelines can reduce LOS, decrease costs, and several have shown a favourable impact on mortality. The majority of these studies have been retrospective reviews. One multicenter prospective, randomised trial of a critical pathway for CAP revealed significant reductions in the hospital admission of patients, LOS and cost of care. Other studies of processes of care have been mainly 'before and after' interventions; many have shown reductions in LOS and costs. Based on the available data, it is reasonable to expect that adherence to guidelines and critical pathways can reduce the cost of care for CAP; however, randomised controlled trials that include a formal cost-effectiveness analysis are needed. Even if the data to support the use of guidelines and pathways are robust, those who develop and implement them need to anticipate and understand barriers to physician adherence.

Anti-Bacterial Agents↗

PubMed1997

Local impact of the NHMRC early breast cancer guidelines: where to from here?

OBJECTIVES: To determine clinicians' recall of the National Health and Medical Research Council's (NHMRC) Clinical practice guidelines for the management of early breast cancer six months after publication, and their reactions to its content and potential dissemination and implementation strategies. SETTING: Greater Western Region of Sydney, May 1996. METHOD: Self-administered survey of clinicians with an involvement or interest in the management of women with breast cancer. RESULTS: Of the 69 respondents to the questionnaire (77% response rate), 20% did not recall ever seeing the guidelines. Although most agreed with the defined parameters of potential strengths of the guidelines, there was less agreement as to their medicolegal implications. The four treatment sections of the guidelines were the most highly rated, followed by the sections on communication skills and investigations. Education programs, including college-based programs, as well as endorsement of the guidelines by the learned colleges and respected colleagues, were rated highly as dissemination strategies, far outranking Internet availability. Local revision of the guidelines was considered important as an implementation strategy by three-quarters of respondents. Only 20% indicated that the guidelines had influenced clinical practice, although 46% agreed that they would improve outcomes for women with early breast cancer. CONCLUSIONS: The NHMRC early breast cancer guidelines have been relatively well received in the Greater Western Region of Sydney, although local activities within public institutions and private practice will be needed to achieve implementation.

Adult↗

PubMed2002

Applying evidence-based guidelines improves use of colonoscopy resources in patients with a moderate risk of colorectal neoplasia.

OBJECTIVES: To determine whether applying National Health and Medical Research Council (NHMRC) guidelines for colorectal cancer prevention would reduce the number of follow-up colonoscopies. DESIGN: A prospective audit of colonoscopic surveillance decisions before and after the intervention. SETTING: The endoscopy suite at a metropolitan tertiary hospital three months before and after January 2000. INTERVENTION: Dissemination of NHMRC guidelines, and supervision of application of the guidelines by a nurse coordinator. SUBJECTS: We compared colonoscopic surveillance decisions before and after the intervention in two groups of 100 consecutive patients after polypectomy and in two groups of 50 consecutive patients with a family history of colorectal cancer after a normal colonoscopy. MAIN OUTCOME MEASURES: Change in concordance of decisions with NHMRC guidelines; and effect on number of follow-up colonoscopies. RESULTS: After the intervention, the proportion of postpolypectomy surveillance decisions matching the guidelines increased from 37% to 96% (P < 0.05). The mean time to repeat colonoscopy after polypectomy increased from 2.7 to 3.5 years (P < 0.005) (ie, a 23% reduction in the number of postpolypectomy surveillance colonoscopies performed per year). Likewise, the proportion of family-history surveillance decisions matching the guidelines increased from 63% to 96%. Adhering to the guidelines resulted in a 17% reduction in colonoscopies performed on the basis of a family history of colorectal cancer. CONCLUSIONS: Supervised application of evidence-based guidelines to a colorectal cancer surveillance program significantly reduces the number of surveillance colonoscopies performed.

Adenoma↗

PubMed2000

The use and perceived value of diabetes clinical management guidelines in general practice.

OBJECTIVE: To assess attitudes to and use of NSW Health Department (NSWHD) guidelines for the clinical management of diabetes mellitus by divisions of general practice, general practitioners, patients and allied health professionals. METHOD: A mail cross sectional survey of divisions of general practice and a series of focus groups of GPs, patients and allied health professionals, on extent of use and perceived usefulness of the NSWHD guidelines. RESULTS: Forty divisions had or recently concluded a diabetes shared care project. Thirteen out of the 31 diabetes projects with guidelines reported using the NSWHD guidelines. Nineteen divisions were aware of the NSWHD guidelines. While the general response to the guidelines in both the survey and the focus groups was positive, there were suggestions for modifications. Many respondents were not aware of the guidelines. CONCLUSION: Optimal use of the guidelines in general practice requires improved dissemination and an implementation strategy based not only on GP education but also systems to reduce barriers to implementation and to support better quality of GP care.

Attitude of Health Personnel↗

PubMed2000

Osteoporosis Clinical Guideline. South African Medical Association--Osteoporosis Working Group.

OBJECTIVE: This Guideline aims to improve the efficacy of both diagnostic and therapeutic interventions for osteoporosis. All health care workers are targeted in the Guideline. A rather detailed summary, which is cross-referenced to the full guideline, is provided to cater for the busy general practitioner. The motivation for the development of this Guideline is based on the facts that: Osteoporosis is a common, costly disease which carries a significant morbidity and mortality, yet is still too often regarded as an inescapable part of normal ageing. Early detection and intervention will be more cost-effective than the treatment of advanced disease. Much confusion exists regarding diagnostic criteria, the assessment of fracture risk, and therapeutic intervention thresholds. A rational approach to drug selection is seldom considered. No consensus guideline on the diagnosis and management of osteoporosis has been published in this country. OUTCOMES: Prevention of fracture and a reduction in morbidity and mortality were the major considerations in the development of this Guideline. Although no formal economic analysis was undertaken, the cost-effectiveness of diagnostic and therapeutic interventions was considered in all recommendations. EVIDENCE: A combination of descriptive, boundary (minimum standards) and algorithmic guidelines was employed. The highest level of evidence (meta-analyses, randomised and controlled studies) was used as far as possible and isolated descriptive studies and expert opinions were largely ignored. A draft guideline was developed, debated at a consensus meeting and finalised on the basis of written comments following the distribution of a second draft. METHODOLOGY: See Annexure B. RECOMMENDATIONS: In the absence of a sound health economic justification for a screening policy, it is recommended that the prevention and treatment of osteoporosis is best managed using a case-finding approach. It is recommended that clinical risk factors--related to bone mineral density (BMD), bone strength or falls--provide indications for further assessment, in particular bone mass measurement. Axial, dual energy X-ray absorptiometry (DEXA) is the preferred technique to assess BMD, to diagnose osteoporosis and to assess rates of bone loss/gain. While the four diagnostic categories proposed by the World Health Organisation (WHO, 1994) provide a practical basis to identify those at risk of fracture, cognisance should be taken of its limitations. We recommend that the BMD of both spine and hip should be measured, that the NHANES III reference data for Caucasians be used for subjects of all races (until local reference ranges for different ethnic groups are established), and that the same absolute thresholds be employed to diagnose osteoporosis in men and women. Recommendations are also made regarding indications for bone mass measurement and selected routine laboratory tests. The differences between diagnostic criteria and intervention thresholds are emphasised. The need to treat should not depend on a BMD value alone, but should also be determined by the patient's age, general health and willingness to consider treatment; the presence of clinical risk factors; prevalent vertebral fractures; and the rate of bone loss/turnover; as well as the cost-effectiveness and side-effects of available treatment. Non-pharmacological measures to improve bone strength include a balanced diet, physical exercise, limiting alcohol consumption, the avoidance of smoking and bone toxic drugs and the prevention of falls. No ideal drug can be recommended for the prevention and treatment of osteoporosis in all patients. The choice of drug is largely determined by the nature of the disease (e.g. antiresorptive agents like calcium (+/- vitamin D) for mild osteopenia, hormone replacement therapy (HRT) or bisphosphonates for moderate bone loss and the addition of a bone formation-stimulating agent in patients with more severe osteoporosis) and the pati

Adult↗

PubMed2001

Clinical practice guidelines for the diagnosis and treatment of respiratory tract infections.

Clinical practice guidelines can be indispensable tools for managed care organizations (MCOs) in providing cost-effective treatment of common conditions. Guidelines for acute respiratory tract infections, such as acute otitis media (AOM) and acute sinusitis, can assist clinicians in accurately diagnosing these conditions, in providing treatment rationales, and in reducing the costs associated with inappropriate antibiotic prescriptions. Barriers to the implementation of practice guidelines include negative attitudes clinicians may have about guidelines promoted by MCOs; patient/parent expectations for antibiotic treatment; lack of financial resources, information system resources, and support for implementation; and lack of commitment to patient and provider education on the part of MCOs. MCOs can facilitate the adoption and implementation of guidelines with a systematic approach that involves establishing a guideline review process, gaining the support of providers, selecting outcomes measures, collecting and analyzing outcomes data, and providing feedback to clinicians about the impact of changes in their practices. This systematic approach should be used as part of the process for the National Committee for Quality Assurance accreditation. Evidence-based clinical practice guidelines for AOM and sinusitis have been developed recently by national consortia of infectious disease experts. Adoption of these guidelines can assist in preventing the spread of resistant pathogens.

Anti-Bacterial Agents↗

PubMed2001

Revised guidelines for HIV counseling, testing, and referral.

These guidelines replace CDC's 1994 guidelines, HIV Counseling, Testing, and Referral Standards and Guidelines, and contain recommendations for public- and private-sector policy makers and service providers of human immunodeficiency virus (HIV) counseling, testing, and referral (CTR). To develop these guidelines, CDC used an evidence-based approach advocated by the U.S. Preventive Services Task Force and public health practice guidelines. The recommendations are based on evidence from all available scientific sources; where evidence is lacking, opinion of "best practices" by specialists in the field has been used. This revision was prompted by scientific and programmatic advances in HIV CTR, as well as advances in prevention and the treatment and care of HIV-infected persons. These advances include a) demonstrated efficacy of HIV prevention counseling models aimed at behavioral risk reduction; b) effective treatments for HIV infection and opportunistic infections; c) effective treatment regimens for preventing perinatal transmission; and d) new test technologies. Although the new guidelines include many aspects of the previous ones (e.g., encouragement of confidential and anonymous voluntary HIV testing, need for informed consent, and provision of HIV prevention counseling that focuses on the client's own risk), the new guidelines differ in several respects, including: giving guidance to all providers of voluntary HIV CTR in the public and private sectors; using an evidence-based approach to provide specific recommendations for CTR; underscoring the importance of early knowledge of HIV status and making testing more accessible and available; acknowledging providers' need for flexibility in implementing the guidelines, given their particular client base, setting HIV prevalence level, and available resources; recommending that CTR be targeted efficiently through risk screening and other strategies; and addressing ways to improve the quality and provision of HIV CTR.

AIDS Serodiagnosis↗

PubMed2002

Primary care guidelines on consultation practices: the effectiveness of computerized versus paper-based versions. A cluster randomized controlled trial among newly qualified primary care physicians.

OBJECTIVE: To compare the effects of computerized and paper-based versions of guidelines on recently qualified physicians' consultation practices. METHODS: Two arm cluster randomized controlled trial. Physicians were randomized to receive computerized or textbook-based versions of the same guidelines for a 4-week study period. Physicians' compliance with guideline recommendations about laboratory, radiological, physical and other examinations, procedures, nonpharmacologic and pharmacologic treatments, physiotherapy, and referrals were measured by case note review. RESULTS: There were 139 recently qualified physicians working in 96 primary healthcare centers in Finland who participated in the study. Data on 4,633 patient encounters were abstracted, of which 3,484 were suitable for further analysis. Physicians' compliance with guidelines was high (over 80% for use of laboratory, radiology, physical examinations, and referrals). There were no significant differences in physicians' consultation practices in any of the measured outcomes between the computerized and textbook group. CONCLUSION: Guidelines are a useful source of information for recently qualified physicians working in primary care. However, the method of presentation of the guidelines (electronic or paper) does not have an effect on guideline use or their impact on decisions. Other factors should be considered when choosing the method of presentation of guidelines, such as information-seeking time, ease of use during the consultation, ability to update, production costs, and the physician's own preferences.

Cluster Analysis↗

PubMed2003

Modifying dyspepsia management in primary care: a cluster randomised controlled trial of educational outreach compared with passive guideline dissemination.

BACKGROUND: Quality improvement initiatives in health services rely upon the effective introduction of clinical practice guidelines. However, even well constructed guidelines have little effect unless supported by dissemination and implementation strategies. AIM: To test the effectiveness of 'educational outreach' as a strategy for facilitating the uptake of dyspepsia management guidelines in primary care. DESIGN OF STUDY: A pragmatic, cluster-randomised controlled trial of guideline introduction, comparing educational outreach with postal guideline dissemination alone. SETTING: One-hundred and fourteen general practices (233 general practitioners) in the Salford and Trafford Health authority catchment area in the northwest of England. METHOD: All practices received guidelines by post in July 1997. The intervention group practices began to receive educational outreach three months later. This consisted of practice-based seminars with hospital specialists at which guideline recommendations were appraised, and implementation plans formulated. Seminars were followed up with 'reinforcement' visits after a further 12 weeks. Outcome measures were: (a) the appropriateness of referral for; and (b) findings at, open access upper gastrointestinal endoscopy; (c) costs of GP prescriptions for acid-suppressing drugs, and (d) the use of laboratory-based serological tests for Helicobacter pylori. Data were collected for seven months before and/or after the intervention and analysed by intention-to-treat. RESULTS: (a) The proportion of appropriate referrals was higher in the intervention group in the six-month post-intervention period (practice medians: control = 50.0%, intervention = 63.9%, P < 0.05); (b) the proportion of major findings at endoscopy did not alter significantly; (c) there was a greater rise in overall expenditure on acid-suppressing drugs in the intervention as compared with the control group (+8% versus +2%, P = 0.005); and (d) the median testing rate per practice for H pylori in the post-intervention period was significantly greater in the intervention group (four versus O, P < 0.001). CONCLUSION: This study suggests that educational outreach may be more effective than passive guideline dissemination in changing clinical behaviour. It also demonstrates that unpredictable and unanticipated outcomes may emerge.

Algorithms↗

PubMed2003

Randomised controlled trial of the impact of guidelines, prioritized review criteria and feedback on implementation of recommendations for angina and asthma.

BACKGROUND: Guidelines are frequently used in an attempt to influence the performance of health professionals, and a national agency has been established in England and Wales to develop and disseminate guidelines. Professionals prefer short guidelines that highlight key recommendations, but whether such guidelines are more likely to be implemented is unknown. AIM: To determine the relative impact of the dissemination of full guidelines, reduced guidelines in the form of prioritized review criteria, and review criteria supplemented by feedback. DESIGN OF STUDY: Cluster randomised controlled trial, with an incomplete block design. SETTING: Eighty-one general practices in Leicestershire, Lincolnshire, Northamptonshire, North Derbyshire, and Nottinghamshire. METHOD: The practices received one of the study interventions, either for care of adults with asthma or for care of people with angina. Data were collected before and after the interventions, the process measures being adherence to ten recommendations about asthma and 14 about angina, and outcome measures being scores in response to an asthma symptom questionnaire or the Seattle Angina Questionnaire, and levels of patient satisfaction. RESULTS: There were no consistent differences between the interventions in stimulating improvements in performance as indicated by adherence to the recommendations for asthma or angina. Patients with angina in practices that had received criteria or criteria plus feedback reported better symptom control. CONCLUSION: The dissemination of guidelines in the format of prioritized review criteria does not increase adherence to recommendations in comparison with the traditional guideline format, and the further provision of feedback has minimal additional effect.

Aged↗