The North Cheshire Health Authority hyperlipidaemia guidelines and dyspepsia guidelines were sent to all GPs, practice nurses and practice managers in October 1997.
A variety of methods were used to aid implementation of the guidelines, including seminars at postgraduate centres, presentations at practices, and lectures at practice nurse, health visitor/district nurse forums.
Between November 1997 and July 1999 a multifaceted study was undertaken to establish whether the guidelines were effective in changing clinical practice. The study was an initiative from North Cheshire Health and the Cheshire Public Health Research and Resource Unit, University College Chester.
A data matrix was designed to evaluate various aspects of clinical guidelines with regard to practice (Table 1). It was divided into two main sections:
|Dissemination and implementation of clinical guidelines|
|Assessing the impact of clinical guidelines.|
Dissemination and implementation
Assessing the impact
Dissemination and implementation of clinical guidelines
All 46 general practices in North Cheshire were included in the study. This involved 155 GPs, 55 practice nurses, 46 practice managers and 220 health visitors/district nurses.
Various aspects of dissemination and implementation were assessed through evaluation forms distributed to all health professionals attending the seminars, presentations and lectures on clinical guidelines.
Assessing the impact of the guidelines
The impact of the guidelines was assessed by means of a questionnaire and analysis of drug prescribing data. Cheshire MAAG also carried out an audit to complement this study. The collective picture was analysed to establish whether clinical guidelines are effective in changing practice.
The questionnaire sought to determine what health professionals thought about clinical guidelines generally and about specific guidelines.
The validity and reliability of the questionnaire were tested in a pilot study. In the main study, all GPs, practice nurses, practice managers, health visitors and district nurses were sent a questionnaire and given the opportunity to comment on various aspects of clinical guidelines.
The drug prescribing data (electronic Prescribing Analyses and Cost; EPACT) were reviewed to identify prescribing trends for lipid-lowering drugs with regard to hyperlipidaemia, and for ulcer-healing drugs in the treatment of dyspepsia. Data from October 1996 until November 1998 were mapped and taken from the database for analysis.
Cheshire MAAG carried out an audit to determine whether health professionals were following the hyperlipidaemia guideline and the dyspepsia guideline. Reports are available on request.
Dissemination and implementation of guidelines
Completed evaluation forms showed that most health professionals preferred to receive information on guidelines through postgraduate seminars. The least relevant sessions appeared to be presentations at primary healthcare team meetings. This may be because clerical staff and receptionists attended these meetings, and would have recorded that information on guidelines was not relevant to their work.
Most health professionals thought that adequate time was allowed for discussion and questions at the postgraduate seminars and the practice nurse forum, which was attended by GPs and practice nurses respectively.
The majority of health professionals appeared to consider clinical guidelines a good idea in practice. Comments included: "Clinical guidelines are a good idea as they can be used as a standard, especially for practitioners, and are also beneficial to clients."
Respondents also suggested that unless all health professionals, especially GPs, utilised guidelines they would not change practice. For example, it was stated: "Clinical guidelines are a good idea as long as everybody works to them and is in agreement with their content" and "Guidelines are valuable and necessary to standardised care, especially if the GPs use them".
The impact of clinical guidelines
Approximately a third of health professionals returned the questionnaire. The response rate was 36% for GPs and practice nurses and 33% for practice managers. The response rate for health visitors and district nurses was low (7%), possibly because they were not based at the practices and may not have received the questionnaire.
Two-thirds of GPs who responded claimed to have seen the hyperlipidaemia and the dyspepsia guidelines and to follow them.
A chi-square test carried out on the hyperlipidaemia guideline showed that among GPs there was a significant association between following this guideline and changing practice (P<0.001). A chi-square test carried out on the dyspepsia guideline also showed a significant association between GPs following this guideline and changing practice (P<0.002).
Similar results were obtained for practice nurses who had seen the guidelines. A chi-square test was not carried out on this group, however, as it contained too few subjects.
Comments regarding clinical guidelines jell into one of two categories: general comments, and specific comments regarding particular guidelines.
One GP commented: "I used to act in a haphazard way before, and I now feel confident with my actions and more competent. I will now use your guidelines". A practice nurse stated: "The guidelines have improved my understanding of the condition and treatment."
Some GPs, however, expressed concerns about clinical guidelines, stating: "I follow my own clinical judgment" and "Will the primary care groups have to take over this role?"
Comments referring to specific guidelines included: "The hyperlipidaemia guidelines are clearer for cholesterol management" and "The dyspepsia guideline clarifies the role of the Helicobacter pylori breath test and eradication therapy."
GPs and practice nurses appeared to value the hyperlipidaemia and dyspepsia guidelines more than other guidelines.
Responses indicate that the majority of health professionals want the development of local clinical guidelines to continue (Table 2).
Analysis of prescribing data
Review of the EPACT data showed that the prescribing rate for lipid-lowering drugs for hyperlipidaemia had risen. Although it cannot be proved that this was a direct result of following the hyperlipidaemia guideline, as other variables, such as input from the community pharmacist and the clinic-dased nurse, may have influenced the rate, the guideline may well have contributed to this effect.
In contrast, the prescribing rate for ulcer-healing drugs had remained stable, and again the dyspepsia guideline may have played a part in this effect. The concern here was whether patients were being prescribed the correct drugs. The fact that the prescribing rate for ulcer-healing drugs remained stable implies that they are receiving the correct drug therapy.
Cheshire MAAG found no real evidence that the dyspepsia or the hyperlipidaemia guideline had been followed in the general practices reviewed (in contrast to the questionnaire results which indicated that two-thirds of GPs followed the guidelines). However, Cheshire MAAG's findings are limited in that the study was retrospective rather than prospective, and only a small number of practices were reviewed.
Some health professionals have reservations about clinical guidelines, but health professionals as a whole appear to find value in them.
Some GPs have said they would rather "follow their own clinical judgment with regard to treating patients". Others, however, view clinical guidelines as a guide in which personal interpretation plays a part, e.g. "I used to act in a haphazard way before, and now I feel confident with my actions and more competent".
Practice nurses believe that clinical guidelines are valuable, and recognise that if they are to be successful, GPs need to follow them. Comments included: "For clinical guidelines to be successful there needs to be co-operation from GPs in order to encourage further use". This insight conforms with the strategic view of Humphris and Littlejohns1 who believe that practitioner's behaviour has to change if clinical guidelines are to be effective.
The development of guidelines
The majority of health professionals in the study thought that clinical guidelines should be evidence based. Comments included: "I think these guidelines are very important as we attempt to integrate research and evidence into practice" and "Following the guideline would depend on the guideline – if it was appropriately evidence based and workable." These views support that of Thomson et al2 who highlight the need to consider research and evidence when developing guidelines.
GPs in particular were concerned about the origin of the guidelines. "I do not like their origin from North Cheshire Health, that there is a large secondary input and that they are not holistic," commented one GP. Thomson et al2 believe it is essential that a multidisciplinary team is involved in the development of clinical guidelines.
Dissemination and implementation
In general, health professionals were satisfied with the way that the guidelines had been disseminated and implemented. When asked how they would prefer to receive guidelines, 60% wanted the guidelines posted to them. Similarly, Grimshaw and Russell3 found that GPs in particular prefer to have clinical guidelines posted to them.
All GPs approved of postgraduate seminars as a way of informing them about guidelines and found the session relevant to their practice. The majority found the presentations ideal. This concurs with Thomson and colleagues' finding that GPs prefer seminars on specific guidelines.2
A high proportion of practice nurses, district nurses and health visitors found the lectures relevant to their work and thought it was a good way of informing them about clinical guidelines, stating, for example: "I found the presentation more useful than any written information". This fits in with the findings of Cheater and Close4 that nurses want clear guidance on guidelines in a teaching format.
Evaluation of clinical guidelines
Health professionals appeared more likely to follow clinical guidelines on some subject areas than others. For example, more GPs had seen the hyperlipidaemia and the dyspepsia guidelines than had seen other guidelines sent out at the same time in the same envelope. These discrepancies were less obvious among the practice nurses.
Adherence to the hyperlipidaemia and the dyspepsia guidelines by GPs was significantly associated with a change in their clinical practice (P<0.001 and P<0.002 respectively).
The increase in prescribing of lipid-lowering drugs for hyperlipidaemia fits in with the hyperlipidaemia guideline. Outcome data for the ulcer-healing drugs show maintenance of the prescribing rate, which the dyspepsia guideline advocates. It can therefore be concluded that although the guidelines may not have been the primary cause of these effects, they may have had some influence.
The use of outcome data to determine the effectiveness of guidelines is debatable. For example, Chaulk and Freake,5 found that clinical guidelines do not consistently result in improvements in clinical outcomes. In contrast, Grimshaw and Russell6 disagree with this view, finding that in all but two of the 11 studies that they reviewed, guidelines had resulted in significant improvement in outcome.
|While some practitioners have reservations about clinical guidelines, health professionals as a whole appear to find value in them.|
Health professionals are more likely to follow clinical guidelines on some subject areas than others, and this needs to be taken into consideration when deciding on subject areas in which to develop further guidelines.
|The hyperlipidaemia and dyspepsia guidelines appear to have had some effect on clinical practice.|
- Humphris D, Littlejohns P. Implementing clinical guidelines linking learning and clinical audit. Audit Trends 1996; 4: 59-62.
- Thomson R, Lavender M, Madhok R. How to ensure that guidelines are effective. Br Med J 1995; 311: 237-42.
- Grimshaw J, Russell I. Achieving health gain through clinical guidelines: ensuring that guidelines change medical practice. Qual Health Care 1994; 3: 45-52.
- Cheater F, Close S. The effectiveness of methods of dissemination and implementation of clinical guidelines for nursing practice: a selective review. Clin Effectiveness Nurs 1997; 1: 4-15.
- Chaulke P, Freake D. In: Worrall G, Chaulk P, Freake D. The effects of clinical practice guidelines on patient outcomes in primary care: a systematic review. Can Med Assoc J 1997; 156: 1705-12.
- Grimshaw J, Russell I. Effect of clinical guidelines on medical practice. a systematic review of rigorous evaluations. Lancet 1993; 342: 1317-22.