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EXPERT STATUS REPORT
Year : 2013  |  Volume : 1  |  Issue : 3  |  Page : 141-147

Expected benefits of clinical practice guidelines: Factors affecting their adherence and methods of implementation and dissemination


Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia

Date of Web Publication30-Oct-2013

Correspondence Address:
Saja H Almazrou Mazrou
Department of Clinical Pharmacy, College of Pharmacy, King Saud University, PO Box 2627 Riyadh 12372-7-524
Saudi Arabia
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  Abstract 

The aim of this paper was to determine the expected benefits of clinical practice guideline implementation, discuss the criteria of a successful clinical guideline, explore the common factors that affect the adherence to their implementation and finally to identify the widely used guidelines dissemination methods.

Keywords: Adherence, clinical practice guidelines, implementation


How to cite this article:
Almazrou Mazrou SH. Expected benefits of clinical practice guidelines: Factors affecting their adherence and methods of implementation and dissemination . J Health Spec 2013;1:141-7

How to cite this URL:
Almazrou Mazrou SH. Expected benefits of clinical practice guidelines: Factors affecting their adherence and methods of implementation and dissemination . J Health Spec [serial online] 2013 [cited 2019 Sep 17];1:141-7. Available from: http://www.thejhs.org/text.asp?2013/1/3/141/120855


  Introduction Top


A search for 'clinical guidelines' on the World Wide Web at this time will result in hundreds of thousands of hits. Even allowing for many duplicates, there is clearly a massive worldwide interest in writing and publishing 'top practice' clinical guidelines, motivated by the aim of encouraging evidence-based clinical practice. [1] Clearly there is benefit in knowing whether a recommendation is based on the results of a well-designed, unbiased study published in a high ranking, peer-reviewed, scientific journal. With this information, a physician faced with a clinical decision can decide whether to follow a particular recommendation based, in part, on the assigned strength of the evidence on which the recommendation was made. [2] The development of clinical practice guidelines (CPG) ensuring the appropriate use of evidence represents one of the core functions of many well recognized national and international originations specialized in many healthcare-related issues. CPG are defined as 'systematically developed statements to assist practitioners and patient decisions about appropriate healthcare for specific clinical circumstances'. [3]


  Expected Benefits from Clinical Practice Guidelines Implementation Top


CPG are considered as one of the most influential and effective tools for the promotion of evidence-based medicine (EBM). [4] CPG are being touted as a cure for the tension between healthcare cost and quality. Rather than being just a means of controlling clinicians, guidelines also offer the chance to improve the quality of care by reducing practice variation and adherence to standards of good care. [5] Guidelines can be used in a wide range of settings to promote effective and efficient healthcare - for example to guide the introduction of new procedures or services, promote effective healthcare in primary or secondary care settings, encourage the adoption of cost-effective interventions and improve the timing and processes of the discharge of patients. [6] Effective implementation of clinical guidelines have also been found to improve clinical outcomes, reduce the length of hospitalization, referral, emergency department (ED) visits, frequency of monitoring and cost are discussed below.

Clinical outcomes

Improvement of clinical outcomes by effective utilization of practice guidelines have been studied in many disease states such as asthma, pneumonia and psychiatric disorders. A recent study carried out in Japan to investigate the variations in the clinical efficacy and drug cost following the introduction of the Asthma Prevention and Management Guidelines (APMG), by reviewing the medical charts of 50 adults outpatients treated continuously for asthma. After the introduction of guidelines, distribution of asthma symptom severity varied significantly (P < 0.0001) and fewer patients were recognized as having more severe asthma symptoms. Significantly, more patients with severe asthma symptoms were detected in the physicians' non-compliant group than in the compliant group (P < 0.0001). The number of patients prescribed with oral corticosteroids, long-acting beta2-agonists containing patches, long-acting oral beta2-agonists, short-acting inhaled beta2-agonists, sustained-released theophylline and leukotriene receptor antagonists decreased after the introduction of the guidelines. [7]

Another study was carried out in Australia to study the effect multifaceted interventions such as small workshops and locally adopted guidelines on health outcomes of children and adolescents with asthma. The adolescents reported an improvement in quality of life subscale score 'positive effects' (mean difference = 2.64, P = 0.01). [8] Although adherence to clinical guidelines have been reported to improve clinical outcomes in asthma, the study published in BMJ oppose these findings. Eccles et al., evaluated the use of a computerized support system for decision making for implementing evidence-based clinical guidelines for the management of asthma and angina in adults in primary care. Assessing adherence to the guidelines was based on review of case notes and patient reported outcomes. The results found that the computerized decision support system had no significant effect on consultation rates, process of care measures (including prescribing), or any patient reported outcomes for either condition. This was probably due to low levels of use of the software, despite the system being optimized as far as technically possible. Even if the technical problems of producing a system that fully supports the management of chronic disease were solved, there remains the challenge of integrating the systems into clinical encounters where busy practitioners manage patients with complex, multiple conditions. [9] The clinical outcomes were assessed in the treatment of pneumonia, a review found that implementation of guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia decreases the rate of initial inappropriate antibiotic treatment and decreased 14-day mortality. [10] However, other reviews concluded that guidelines implementation can improve outcomes. To achieve this goal, guidelines should be adapted to local microbiology, accurately predict ventilator associated pneumonia pathogens and help physicians to administer the most appropriate empirical antimicrobial therapy. [11] Psychiatric disorders such as depression and anxiety have been investigated in terms of clinical improvement after guidelines adoption. A study carried out by Hepner et al., to estimate how frequently specific guideline recommendations are followed and to assess whether following guideline recommendations is linked to improved depression outcomes. Greater adherence to practice guidelines predicted significantly fewer depressive symptoms. [12] In contrast, a review published by Baldwin et al., which include a number of RCTs in anxiety, panic disorders and depression, found that introducing guidelines does not significantly improve the clinical outcomes. The disappointing nature of these findings may be attributed to many reasons such as difficulty in diagnosing psychiatric disorders. In addition, it was noted that many physicians doubt the effectiveness of anti-depressants. [13]

Hospitalization and ED visits

The impact of adherence to CPG on hospitalization have been studied by Sloan et al. The research objective was to study the discrepancy between actual and recommended rates of use among several measures of screening for complications of diabetes in a national longitudinal sample, the correlations among measures of adherence, and whether or not higher rates of adherence reduce hospitalizations for complications of diabetes. The results found that increased rates of adherence were observed for HbA1c and lipid testing over the observation period. Higher use was associated with significantly lower rates of hospitalization for vascular, renal and other complications of diabetes. [14] Furthermore, adherence to guidelines not only reduces hospitalization but also reduces the emergency and outpatient visits for children with asthma. This has also been concluded by Cloutier et al.; their study aimed to determine whether adherence to the guidelines by primary care providers (PCPs) decreases medical services utilization in low-income, minority children. After enrolment in easy breathing, provider adherence to the National Asthma Education and Prevention Program (NAEPP) guidelines, children with asthma experienced a 35% decrease in overall hospitalization rates (P < 0.006), a 27% decrease in asthma ED visits (P < 0.01) and a 19% decrease in outpatient visits (P < 0.0001). [15]

Referrals

In a recent systematic review, assessing the effectiveness of guidelines for referral for elective surgical evaluation, found that guidelines for elective surgical referral can improve appropriateness of care by improving pre-referral investigation and treatment. [16] An audit was undertaken by Hill et al., to assess how appropriate referrals were just before and after spreading of the guidelines and was repeated 2 years later to determine whether they had made any substantial impact. The results revealed a 40% increase in the number of appropriate referrals immediately after introduction of the guidelines, but this was not sustained 2 years later. The study concluded that there is a need for continued general practitioner education support referral guidelines. [17]

Use of diagnostic tests

Other expected benefits of using practice guidelines are the reduction in the frequency of laboratory monitoring. Using a retrospective chart review, Gentile et al., compared the use of chest radiography (CXR) and arterial blood gas testing (ABG) before and after initiation of specific ordering guidelines, after guideline initiation, there was a 55% reduction in the number of chest radiographs. Of the patients who did not have a chest x-ray in the ED, none had an abnormal chest x-ray obtained after admission or if they returned to the ED within 72 hours. There was a 57% reduction in the number of ABGs. Although patients with abnormal ABGs had an apparent indication for testing, all of the ABGs for which no indication could be found were normal. A protocol containing criteria for obtaining chest x-rays and ABG testing can reduce the use of diagnostic testing, thereby improving ED efficiency without adversely impacting patient care. [18]

Cost

Many studies also suggest that successful implementation of CPG can save cost. A study was undertaken by Prat et al., to assess the impact of clinical guidelines to improve appropriate use of routine laboratory tests and bedside chest radiographs in a 15 bed medical intensive care unit. They found that an overall 300,000 Euros intensive care unit (ICU) cost reduction was directly related to the protocol implementation. [19] Baer et al., discovered that electronic neonatal intensive care unit (NICU) transfusion ordering and monitoring system as part of a new program to improve compliance with transfusion guidelines, resulted in an annual decrease of $780,074 in blood bank charges. [20] Recent research in Japan investigated the variations in the clinical efficacy and drug cost following the introduction of the APMG, the results found that the total annual drug cost per patient decreased significantly by an average of 16,259 Yen, US $165 (P = 0.006). [7] Although many studies provide evidence that effective implementation of practice guidelines can save cost, there are some contradictory findings discussed by McColl et al., which states that 'clinical guidelines will be cost effective only if the resources spent to develop and disseminate them are justified by reductions in healthcare expenditure or improvements in patients' outcomes. There is very little evidence so far that guidelines are helpful in terms of cost containment'. [21] Fortunately, more studies have been carried out in the past decade to support that following practice guidelines is cost effective in many disease states as discussed earlier.


  Successful Clinical Guidelines and Updating Top


There are many methods used in the development of guidelines, including explicit approach, consensus conference/working party, synthetic method and health economics. [22]

The development of a good guideline requires the active participation of key clinical staff, a systematic review of the scientific evidence, the linking of that evidence to the guideline recommendations and careful attention to other quality criteria such as clarity and clinical flexibility. A successful clinical guideline should correctly interpret the available evidence in order that, when followed, guidelines lead to improvements in health. And when given the same evidence, another guideline group would produce similar recommendations. In the same clinical circumstances, another health professional would apply these guidelines similarly. Guidelines should be representative of all key disciplines and interests (including patients), clinically applicable with a clear definition of the target population and identify where exceptions to the recommendations lie. Furthermore, it must be clearly expressed using precise definitions, unambiguous language, a user-friendly format and clear links of recommendations to the available evidence. Finally, the guidelines should state when, how and by whom they are to be reviewed. Significant resources are being expended internationally on the progress of CPG. [6]

Clinical guidelines require updating. The majority of recommendations can become outdated due to changes in research findings and recently available diagnostic or therapeutic interventions. In general, guidelines should be re-assessed for validity every 3 years. In rapidly evolving fields, for example acquired immunodeficiency syndrome (AIDS) or colonic cancer, yearly review is necessary. [23]

Although consensus is increasing about methods for developing evidence-based guidelines, still less consideration has been paid to the process for assessing when guidelines should be updated. There are some situations that require clinical guidelines updating such as: (i) Changes in evidence on the existing benefits and harm of interventions. (ii) New information about the magnitude of benefits and harm may make the pre-existing guideline invalid. (iii) Changes in outcomes considered important. (iv) New evidence may identify an important outcome that was previously unappreciated or unrecognized. (v) Quality of life, for example an end point often not considered in earlier research and guidelines, is receiving increasing recognition as an important outcome of healthcare. (vi) Changes in available interventions since the development of a guideline, new preventive, diagnostic or treatment interventions may have emerged to complement or supersede other interventions. (vii) Changes in evidence that current practice is optimal, guidelines are developed to help narrow the gap between ideal and current clinical practice. This gap could narrow over time to the point that a guideline is no longer needed. (viii) Changes in values placed on outcomes, the values that individuals or society place on different outcomes may change over time. Economic issues, for example have received little attention in most guidelines but will be considered explicitly in guidelines developed by the UK National Institute for Clinical Excellence. (ix) Changes in resources available for healthcare guidelines may need to be updated to permit increased delivery of services if the level of available resources increase over time. [24]


  Factors Affecting Guidelines Implementation Top


Increasing efforts are being taken to translate guidelines into clinical practice, but many factors affect physicians from adopting them. There is a growing literature that explores the barriers to the implementation of clinical guidelines in healthcare, and that identifies effective strategies for translating research into practice. Although most guidelines are useful tools to provide the busy clinician with up-to-date information, physicians may regard guidelines to be unrealistic, and some may even consider guidelines to be a challenge to their autonomy. A further hazard of guidelines is that they may inhibit research or innovation. [22] These barriers can be classified into organizational and resources, physicians and guidelines-related factors.


  Organizational and Resource Related Factors Top


Effective organizational structure with strong leadership and a powerful learning culture were found to be important facilitating factors in implementing CPG. Additionally, supporting guidelines adoption by the department chief and mandating the guidelines implementation with a multi-disciplinary team is also considered to be successful modalities in working with guidelines.

Lack of financial resources was also raised as an essential issue that prevents the progress of implementation work. Finally, consistent evaluation of the quality of the care provided by giving feedback on the organization's performance will ensure the durability and efficiency of implementation strategies. [25]


  Physicians' Related Factors Top


The degree to which clinicians adhere to guidelines has been the subject of numerous studies, usually based on surveys of real world practice. Studies found that knowledge, attitude and behaviour are considered the main factors that affect physicians' adherence and will be discussed as follows.

Knowledge

Although CPG have been promoted widely, there is considerable concern that physicians have not incorporated them into their practice. Knowledge such as lack of familiarity and awareness, volume overload, time needed to stay informed and guideline accessibility are important in modifying physician practice patterns. [26]

Forsner et al., addressed other physician-related barriers such as lack of research skills and specialized training. [25] Lacking these skills may lead to inability to find the most appropriate resources for evidence-based guidelines.

Attitude

Physician attitude about practice guideline is another barrier to guideline adherence. Lack of agreement and confidence with specific guidelines, that explain that most individual doctors may not agree with guidelines issued by their own peers, leading them to choose a different course of treatment, however, many doctors have seen that a specific guideline may be too rigid to apply. Also lack of outcome expectancy, self-efficacy and motivation to implement practice guidelines in addition to habit and routines have also been found to hinder effective practice guideline implementation.

Behaviour

This is considered as an external barrier, which includes patient, guideline and environmental-related factors. [26] Francke et al., found that patient-related characteristics may include the fact that some patients perceive no need for guideline recommendations or resistance towards the guidelines recommendations as a factor negatively affecting the adoption of clinical guidelines. [27] The guideline factors such as the presence of contradictory guidelines and environmental factors including lack of time, resources and reimbursement. Organizational constraints and perceived increase in malpractice liability are the most important external barriers that affect guidelines implementation. [26]


  Guideline-Related Factors Top


CPG should be compatible with existing values among the target group and not be too controversial. They should not demand too much change to existing routines and be defined precisely, with specific advice on actions and decisions in different cases. They should be compatible with current values and routines. Indeed, some recommendations probably expressed what general practitioners were already prepared to do. The scientific basis of the recommendation is also important. Recommendations were more adhered to when an explicit description of the scientific evidence was available and the evidence was straightforward and not conflicting. The perceived consequences for doctors and practice management matter. A recommendation was used less when compliance affected the organization of and staff in practices, when it demanded extra resources or acquisition of new knowledge and skills, or when it provoked negative reactions in patients. [28]

In a recent meta-analysis published in 2008, it suggested that the most frequently described guideline characteristic concerns complexity. Guidelines that are easy to understand, can easily be tried out and do not require specific resources have a greater chance of being used. [27]


  Professional Dissemination and Implementation Top


Although barriers exist, many dissemination and implementation strategies aim to improve adherence to CPG. The most common strategies are listed below:

Distribution of educational materials in paper or electronic versions, small laminated cards, posters available where care was delivered and short versions of the guidelines posted. Furthermore, reminders are being utilized in guidelines implementation as well. Reminder is a patient- or encounter-specific information, provided verbally, on paper or on a computer screen, which is designed or intended to prompt a health professional to recall information. This would usually be encountered through their general education, in the medical records or through interactions with peers, and so remind them to perform or avoid some action to aid individual patient care. Computer-aided decision support and drugs dosage are included. [29] Unlike educational materials, reminders are patient specific and can be electronic pop-ups that appear on the screen when a chart is opened or a paper reminder placed in the chart, such as a pharmacist note advising clinicians that a patient requires blood tests to ensure toxicity is not an issue with a drug, or that a particular medication may be better for a patient based on best evidence. Reminders are more targeted and less passive than general educational materials. [30]

Other widely used methods are audit and feedback by giving a summary of clinical performance of healthcare over a specified period. This summary may also have included recommendations for clinical action. The information may have been obtained from many resources such as medical records, computerized databases or observations from patients. [29] Audit and feedback could be provided to individuals or the team as a whole. By understanding how close or not to targets team members were is an approach to either celebrate success, or examine issues that may be preventing adequate adherence to a guideline. [30]

Additionally, educational outreach visits by using a trained person or team of healthcare professionals from another institution or organisation who met with providers in their practice settings to give information with the intent of changing the provider's practice. The information given may have included feedback on the performance of the provider(s). Many other less common strategies were used in guidelines implementation such as local opinion leaders and the consensus process, patient mediated intervention, marketing and mass media. However, there is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgment about how best to use the limited resources they have for clinical governance and related activities to maximize population benefits. [29] Technology plays an important role in the implementation and dissemination of practice guidelines but further studies are needed to demonstrate their effectiveness and cost implication. A study aimed at examining whether Palm Prevention, a free software tool for Palm OS personal digital assistants (PDAs) that provides quick access to preventive guidelines in a patient-specific manner at the point of care, improved adherence to five preventive measures in primary care. The results suggested that PDAs are useful in improving preventive care and facilitating translation of knowledge into practice. This was particularly apparent with newer guidelines. [31]

Furthermore, educational games are of growing interest and have the potential to improve adherence to practice guidelines. Research was carried out to develop an educational game to teach clinical guidelines in internal medicine residency programs and to evaluate its feasibility and acceptability. The Guide-O-Game© is a multimedia interactive tool in the format of a TV game show with questions based on recommendations of practice guidelines. The study findings suggest that an educational game is feasible and acceptable. Future work should evaluate its impact on educational outcomes. [32]

 
  References Top

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13.Baldwin DS. Evidence-based guidelines for anxiety disorders: Can they improve clinical outcomes? CNS Spectr 2006;11(10 Suppl 12):34-9.  Back to cited text no. 13
    
14.Sloan FA, Bethel MA, Lee PP, Brown DS, Feinglos MN. Adherence to guidelines and its effects on hospitalizations with complications of type 2 diabetes. Rev Diabet Stud 2004;1:29-38.  Back to cited text no. 14
    
15.Cloutier MM, Hall CB, Wakefield DB, Bailit H. Use of asthma guidelines by primary care providers to reduce hospitalizations and emergency department visits in poor, minority, urban children. J Pediatr 2005;146:591-7.  Back to cited text no. 15
    
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Professional Dis...
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