Q I have recently received three different guidelines about lipids, but they have different recommendations about when to treat patients. Which guideline should I choose?
A There are several standardised methods for evaluating guidelines, and there are some very simple steps you can take initially.
First, which of the three guidelines have been developed for primary care, and which are particularly related to the type of patients you see?
When you have identified the guidelines that are most relevant to your patients in your clinical setting, you need to pick the ones which have been developed most carefully.
You should check which of the guidelines are genuinely evidence-based. What has each one to say about how it was developed?
Do they include information about literature searches that were used, and methods used to appraise the quality of studies found, and how they decided which studies were of good quality? Are the recommendations explicitly linked to the strength of the evidence? If none of the guidelines have been developed in this way, you may choose to ignore them all.
Q My health authority has issued guidelines on the management of peptic ulcers, but I do not agree with their recommendation about proton pump inhibitors. How should I challenge this?
A The first step that you could take in assessing the guidelines is to appraise their validity in general. This would involve checking the methods used to develop the guidelines, in particular the extent to which reliance was placed on evidence rather than opinion. If the guidelines were largely based on the opinion of local or national specialists, you are in a good position to challenge them.
You may also wish to challenge the particular recommendation about proton pump inhibitors. In this case, you will need to assess the evidence that supported the recommendations in the guidelines.
You may wish to read the papers that are quoted. A more detailed approach would be to seek out the evidence yourself, undertaking a systematic search.
If you have found evidence to support your view, take it up with the public health department at your local health authority. It is worth noting that the process of challenging guidelines can be time consuming. However, personal exploration of the primary evidence can be rewarding.
Q Guidelines are often very useful, however they sometimes exclude particular groups of patients, for example elderly patients on lipid-lowering therapies. This means that as doctors we are still not in the best position to advise patients. How can we overcome this?
A The evidence is often based on work done in secondary care managed by consultants. It does not always apply to the patients that GPs normally see.
Guidelines are just that, i. e. they have to be interpreted in relation to the patient in front of the clinician. There may well be perfectly good reasons for not following guidelines in an individual case, though consideration should always be given as to why the guidelines are not being followed in that particular case.
Various figures are quoted for the amount of evidence-based interventions that clinicians offer to their patients. Figures of up to 70% have been quoted in primary care.
Therefore, the evidence is lacking for many particular groups of patients, such as the example quoted in the question. Doctors have, therefore, to acknowledge that they are not necessarily best placed to advise patients on the basis of the evidence available. Cost effectiveness also has to be considered when implementing clinical effectiveness, especially where the evidence is either lacking or thin on the ground.
Q How can I find guidelines on the primary care management of epilepsy?
A First of all contact your local Primary Care Audit Group. They may be able to produce guidelines for you or suggest other people to contact.
Alternatively, the audit group may take on the task for you, as they can get in contact with other organisations such as the Eli Lilly National Clinical Audit Centre, The National Centre for Clinical Audit and the Royal College of Physicians.
You can also undertake searches yourself. You could use MEDLINE in the medical library and search for guidelines. MEDLINE recognises 'guideline' as a search term and by combining 'guideline', 'epilepsy', and 'primary care' into a search term you should come up with a selection of publications. One advantage of searching in this way is that you are also likely to find good quality guidelines produced outside this country.
Q Not all our patients are as straightforward as guidelines would like to suggest. The complexity of their multiple pathologies make it difficult to follow guidelines. When will we see guidelines which take into account some of these difficulties?
A Guidelines are not rigid structures that have to be implemented at all costs. They should acknowledge patient individuality and the ability to interpret guidelines for the individual with complex medical problems. Guidelines should be easily used and reproducible. Therefore, guidelines used in everyday practice will not be able to take account of the huge complexity of multiple pathologies. Surely this is where the art and science of medicine come together.
As guidelines develop and become more accepted then specific questions can be posed so that the evidence base can be accessed to see whether they can be answered and therefore, included in more comprehensive guidelines.
Perhaps it is the responsibility of the clinician who is observing the complexity of the multiple pathologies to develop local guidelines to address the questions being raised.
Q Guidelines often seem to disregard the costs of the recommendations they make. They therefore leave doctors willing, but not able, to meet the expectations.
A If guidelines are written purely on the basis of the evidence base available then it is quite likely that the cost-effectiveness of the management intervention may not have been considered.
However, if the cost-effectiveness matters have been debated then it is up to the purchasing body to prioritise the intervention with respect to the other developments and services in the locality. As members of primary care groups, GPs should be increasingly involved in that debate.
GPs have always been gatekeepers to the NHS and have always had a role in determining the implementation of interventions that have a significant cost.
A delicate balance exists between "doing the right thing, to the right patient, at the right time" and the availability of resources to meet that demand.
A good example of the problems raised by this question is that of the SMAC guidelines on cholesterol lowering drugs. In these circumstances most clinicians would agree that efforts should be made to concentrate on secondary prevention, where the greatest health gain could be achieved for the limited amount of money available.
Primary prevention guidelines should be deferred until the secondary prevention guidelines have been implemented and additional resources identified.
Q As keen as I might be to follow guidelines, I also have to encourage my patients, partners and colleagues in the secondary sector to follow the same guidelines, which is much more difficult.
A This question reaches to the heart of implementing guidelines. The standard line is that if individuals are involved in the development of the guidelines then they are far more likely to implement them. Obviously this can only apply to a limited number of individuals and it is then expected for all the other clinicians to follow them.
Therefore, there has to be an incentive of one sort or another to encourage individuals to follow the guidelines. This could be as simple as the professional ethical high ground where there is sufficient buy in to improve patient care that clinicians will logically follow guidelines to produce health gain.
Peer pressure and the outcomes of clinical audit have a very large part to play in implementation. The influence primary and secondary care doctors have on each other is very significant.
If there is a good evidence base and GPs speak in sufficient numbers to their consultant colleagues then it is more likely that those consultants will also follow the guidelines.
Clearly a conscientious approach to the implementation of guidelines is the best way forward and should be encouraged. However carrots and sticks within the system often have to be used to encourage the initial contacts and follow up.
Lack of concordance and compliance by patients is always hailed as a major block to implementation of guidelines.
It has been shown in practices that targeting resources both human and financial on those groups that do not comply can be very rewarding in terms of outcomes.
The way that we have addressed this issue locally is to agree proxy outcome standards for a number of disease areas which we would expect to be delivered for our family and friends. It is very difficult then for individuals to argue against the principle of following agreed guidelines in these situations.
Q In our practice, we would like to develop our own guidelines for major chronic conditions. Is this a good idea?
A It is very difficult for a practice to develop its own evidence-based guidelines for the majority of major chronic conditions that we manage.
The volume of literature that would have to be reviewed and the complexity of assessing the literature would pose an enormous challenge.
It would be much more sensible to identify some good quality guidelines that have been developed by people with the time, expertise and the money to review the literature carefully.
By all means adapt such systematically developed guidelines to meet your particular needs, but think very carefully before trying to develop you own guidelines from scratch.