Discrepancies exist between general practitioners' clinical work and a guidelines implementation programme

Getting a Better Grip on Research: The Maze of the Most Busy Life

This is the fifth paper in a series of five describing the use of evidence to support decisions made in clinical practice. In the 21st century, health care clinicians, managers and patients expect to see the findings of research incorporated into clinical practice, taking into account the needs and wishes of individual patients. In the previous four papers in this series of five, we have examined why that happens—and often does not happen—and what clinicians and managers can do to improve the use of evidence in consultations. This, the final paper, is written as if from some point in the near future and uses a narrative approach to describe a clinician's progress on a journey to meet the real-world challenges of using evidence in practice.

Knowledge of guidelines for the management of COPD: a survey of primary care physicians

OBJECTIVES

To evaluate primary care physicians' knowledge of guidelines for the management of COPD.

METHOD

Survey to 455 primary care physicians in private practice in the state of Geneva, Switzerland, and to 243 physicians practicing in Geneva University Hospital.

RESULTS

Although 75% of respondents identified that the prevalence of COPD was increasing and 33% recognized it as a major public health issue, only 55% of physicians used spirometric criteria to define COPD, and one-third knew the correct GOLD criteria. Fifty-two percent felt uncomfortable with smoking cessation counselling. Sixty-two percent administered influenza vaccination annually and 29% had immunized their patients against Pneumococcus. Beta2-agonists were the first-line treatment for 89% of physicians, but 10% overestimated their clinical benefit. Twenty-five percent of respondents used systematically inhaled corticosteroids, but 46% ignored their indications. Oral corticosteroids were used by 42% of physicians outside of acute exacerbations. Seventy-nine percent thought that oral steroids had a beneficial effect on stable COPD. Finally, pulmonary rehabilitation was underused by 72% of physicians.

CONCLUSIONS

This study shows major gaps in the knowledge of all core elements of guidelines for the management of COPD and identifies targets for future educational programs.

The doctor, his patient, and the computerized evidence-based guideline

This paper explores some of the issues raised by the finding in a randomized controlled trial (RCT) that general practitioners (GPs) taking part failed to use a computerized evidence-based guideline, nor did it have any impact on patient outcomes. GPs are expected to 'make an initial decision on every problem [patients] may present' and to address psychological and social problems in addition to biomedical ones. The computerized guideline imposed an external, largely biomedical, agenda that superseded the patient's. This disrupted the normal pattern of GP consultations and it was therefore ignored. Guidelines for any particular disease are effective if backed up by a detailed programme of education and audit. However, the large number of different conditions seen in general practice means that it is impractical to have such programmes for more than a small fraction of the clinical workload. The reductionist assumptions underlying the construction of evidence-based guidelines from systematic reviews lead to inflexible recommendations on the management of disease. Anthropologists and sociologists make an important distinction between scientifically defined diseases and the culturally constructed experience of illness. Because GPs deal with patients suffering illness that may or may not result from disease, disease-centred guidelines often conflict with their needs and wishes. The development of evidence-based medicine (EBM) was intended as a tool to help doctors make sense of evidence in the context of individual patients' problems. Few GPs are skilled in it, and it has been appropriated by powerful expert groups such as guidelines developers and the pharmaceutical industry. It is suggested that more understanding of EBM by GPs leads to better informed decision making by them and their patients.

Making research relevant to the primary health care team

There is, as yet, no strong culture of research in primary care and much of the existing research is conceived and undertaken by people outside primary care. The poor implementation of research findings may, in part, be owing to the fact that those delivering the service are not involved in asking or answering questions that are relevant to their practice. This paper reports how three practices constructed a research agenda based on the unanswered questions of their primary care teams. The research questions prioritised by the teams tended towards patient behaviour and service organisation rather than clinical issues. This contrasts with national research priorities. The process has contributed towards the development of a culture of enquiry among team members. Other primary care teams may benefit from a similar approach. National research priority setting in primary care should take more account of the unanswered questions of primary care teams.

Decision making, evidence, audit, and education: case study of antibiotic prescribing in general practice

OBJECTIVES

To describe a group general practice's implementation of a decision to prescribe 3 day courses of 200 mg trimethoprim twice daily for urinary tract infections in women and to compare 3 day courses with 5 and 7 day courses.

DESIGN

Record review, audit of trimethoprim prescribing for urinary tract infections, and critical appraisal of evidence originally presented in support of 3 day course.

SETTING

Group general practice in Newcastle upon Tyne.

DATA SOURCES

The records of all female patients aged 12 years and older who were prescribed trimethoprim for uncomplicated urinary tract infections during a 12 month period were reviewed. 271 valid records were identified.

DATA EXTRACTION

Prescribing rates for different courses of trimethoprim, rates of patients returning for second consultations, rates of urine cultures, results of cultures, results of critical appraisal of evidence.

RESULTS

114 of 271 (42%) prescriptions written at the first visit were for 3 day courses. 16 of 114 (14%) patients who had had a 3 day course of treatment returned for a second consultation compared with 6/83 (7.2%) of those who had had a 5 day course and 8/74 (11%) who had had a 7 day course. The difference between 3 day and 5 day courses in rates of returning for second consultations was 6.8% (95% CI -1.7% to 12.6%) and between 3 day and 7 day courses was 3.2% (-3.6% to 10.0%). Appraisal of the original evidence on which the practice based its recommendations showed that it was flawed. Additional evidence was found in the Cochrane Library.

CONCLUSIONS

Our original decision, made by consensus at a meeting of the practice's partners, had not led to a consistent change in practice. We did not find a significant increase in treatment failures among patients treated with the 3 day regimen.