Regional guideline for diagnosis and treatment of squamous cell carcinoma of the lip: what is the level of compliance?

Clinical practice guidelines: a critical review

PURPOSE

Clinical practice guidelines (CPGs) have been developed for many years with the aim of improving the quality of care. A review of the use of CPGs and assessments of CPG compliance among practitioners so far would aid the understanding of factors influencing CPG compliance. This study seeks to provide this.

DESIGN/METHODOLOGY/APPROACH

A general review and discussion of CPGs in areas of their attributes, benefits and pitfalls were carried out. Articles concerning the assessment of CPG compliance were also reviewed to understand the kind of data collected for such assessments (qualitative vs quantitative), the methods used to collect data (objective versus subjective), and the assessment measures employed (process versus outcome).

FINDINGS

A total of 57 CPG compliance assessment studies were reviewed. Almost two-thirds employed objective methods. Of the subjective assessments, 47 per cent analysed solely quantitative data, 32 per cent analysed solely qualitative information and 21 per cent analysed both. More than four-fifths of all studies used process measures to determine CPG compliance and only 5 per cent used solely outcome measures.

PRACTICAL IMPLICATIONS

Depending on the methods used, assessments can help identify various factors influencing CPG compliance. Such factors may be related to the physician, guidelines, health system or patient. A good understanding of these factors and their role in influencing compliance behaviour will help health regulators and administrators plan better and more effective strategies to improve doctors' CPG compliance.

ORIGINALITY/VALUE

This review looks at the various aspects of CPGs to understand how these influence practitioners' compliance.

Guidelines in head and neck oncology compliance and consequences of deviations from the standard protocol for tongue and floor of mouth squamous carcinoma

OBJECTIVES

To investigate the extent of violation of a regional guideline for the treatment of patients with carcinoma of the tongue/floor of mouth (ICD0 C02, C04). Different aspects of protocol violation (i.e. undertreatment or overtreatment) and consequences for treatment outcome were evaluated.

DESIGN

Retrospective analysis of data from medical records.

SETTING

The Department of Maxillofacial and Oral Surgery and the Department of Otorhinolaryngology and Head and Neck Surgery of the University Medical Centre Utrecht.

PARTICIPANTS

A total of 217 patients treated between 1991 and 2001 for a stage II and stage III carcinoma of the tongue/floor of mouth.

MAIN OUTCOME MEASURES

Protocol violation, tumour recurrence.

RESULTS

The overall adherence to the guideline was 55%. In the non-adherence group of patients, 21% were overtreated, 71% were undertreated, and 8% were both overtreated and undertreated. There was no statistically significant difference in tumour recurrence between the two groups for stage II (P=0.68) or stage III (P=0.97) disease, or between undertreatment and overtreatment of patients with stage II (P=0.47) or stage III (P=0.90) disease.

CONCLUSIONS

Although protocol violation occurs in as many as 45% of patients, this does not result in a worse tumour recurrence. Neither overtreatment nor undertreatment appears to affect the overall tumour recurrence.