Q Some guidelines lay down clear and logical pathways of treatment, but seem to lack evidence for one or more steps they recommend. Can we safely modify these to suit our local practices?
A I suspect that the questioner has a particular set of guidelines in mind when he asks this question. To give a specific answer would require more knowledge of the treatment pathway being referred to. In general terms, however, the question raises the issue of producing and implementing guidelines.
In an ideal world there would be evidence to answer all the questions and produce algorithms of treatment to suit the variety of patients presenting with the same disease.
There would also be access to adequate and timely investigations at local hospitals or laboratories with reasonable access to specialist opinion. However, this is rarely the case and we have to modify guidelines to suit local circumstances. However, we should be careful not to ignore the evidence, where this is clear, to suit our perhaps long-held idiosyncratic views of managing the condition.
Q We receive guidelines from various interest groups. Are all guidelines as reliable as each other? Is there anything equivalent to a Kite Mark?
A Guidelines are only as good as the people who write them, on the date that they are written. Those written by national bodies, such as the Royal Colleges, are obviously far more reliable than perhaps those produced by a local interest group or individuals with an 'interest'.
Where is no equivalent to the Kite Mark as yet, although NICE is expected to produce evidence-based guidelines. However, it will be some time before a significant number of these are produced to make a difference to current practice.
Until then it is always best to consider national guidelines. It is important to look at the date that the guidelines were produced and which organisations were responsible for their production.
Q Is audit a useful tool in our approach to applying guidelines?
A The audit cycle should always be completed, otherwise clinicians will never be sure that they have achieved the standards that they have set for each of the guidelines.
Once the guidelines have been agreed by the primary care team members involved in implementing them, the success criteria should be determined and then the standards for each criterion should be agreed. The practice should then do an initial data capture to analyse where the practice stands against its own standards and criteria. After an agreed interval, the audit cycle should be completed with a second data captureNto see whether there has been an improvement towards the agreed standards.
An example might be as follows for the management of hypertension. Criteria: patients should have their blood pressures controlled to less than 160/90mmHg unless there are contraindications. Standard: by 1/1/00, 70% of all diagnosed hypertensives should have their blood pressure controlled to less than 160/90mmHg.