Towards efficient guidelines: how to monitor guideline use in primary care
Hutchinson A, McIntosh A, Cox S, Gilbert C
Record ID 32003001074
The study aimed to develop a guideline-use monitoring framework in primary healthcare settings. There were four objectives:
- to develop a conceptual framework for guideline-use monitoring in primary care to identify the principles that users require for using routine data monitoring of guidelines - to use survey techniques to review guideline monitoring issues of significance to users, including acceptability, practical applicability and cost in routine practice - to develop a framework for monitoring the use of both consensus-based and evidence-based guidelines - to test the model in a limited manner, to determine usefulness in terms of acceptability, practicality, cost and effort required by those using the framework.
Authors' results and conclusions:
A conceptual framework to support guideline-use monitoring in primary care has been developed, through an amalgam of quality improvement principles from the international literature and an exploration of the requirements of practitioners at three levels in the NHS: general practice, PCGs and Health Authorities. Clinicians see benefits in having systems that can be used to evaluate how well clinical teams are performing against evidence-based clinical standards. However, few have much experience of using guidelines and then assessing conformance with the recommendations. More importantly, many clinicians have concerns about the demands that such systems would place on them in terms of time and cost. Many also have concerns about the confidentiality of information transfer outside the clinical unit. In particular, clinicians had problems with the notion that someone in, for example, a PCT might be monitoring the quality of their care, although many respondents recognised that clinical governance required conformance with standards and that some form of internal and external assessment was required.
Demands on time and the variation in practice computing systems meant that it was only possible in this study to capture review criteria information onto paper-based records, although most of these data were actually held on computer systems. There was a very high level of conformance of the practice teams with guideline recommendations for the management of asthma and stable angina, although the nature of the retrospective data capture meant that the clinical teams had not had prior sight of the guideline recommendations. It appears to be more problematic to capture outcome data from patients, perhaps because of the need to capture new information and to seek informed consent in a study (which would not be required in routine clinical practice).
A costs framework has been developed that can be used to explore the potential costs of guideline-use monitoring and may be of assistance in exploring the wider cost implications of clinical audit at the general practice level.
Methods have been demonstrated that would enable primary care teams and PCTs to monitor clinical guideline conformance while understanding the problems of both the practical and the human issues in establishing the systems.
Effective methods can be developed for monitoring guideline use in primary care. The practical difficulties relate to two main issues. The first is the technical issues concerned with efficient capture of clinical information and its evaluation; in particular, the existing variation in expertise in computerised information, and the need for training of teams in the use and meaning of process and outcome information related to guideline recommendations. The second, and more problematic, issue is the limited degree of understanding that many primary healthcare professionals have of the concepts and practical issues in the area of guideline-use monitoring, and of expectations of this within the NHS.
Surveys, case study
English language abstract:
An English language summary is available
- Practice Guidelines as Topic
- Primary Health Care
NIHR Health Technology Assessment programme
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