Abstract
Clinical practice guidelines (CPGs), particularly those based on evidence-based medicine, have become increasingly popular. There are many reasons for this, chief among them the large amount of medical literature that a physician must read and synthesize. This is particularly difficult for general practitioners (GPs), who must be knowledgeable in many medical disciplines. This may, in part, explain why there is such a wide variation in physician practice patterns and health service utilization, some of which may be inappropriate and lead to suboptimal outcomes for unacceptably high costs (1–4).
The basic tenet of CPGs is systematically to combine scientific evidence and clinical judgement to produce clinically valid operational recommendations for appropriate care. These can then be used to persuade clinicians, patients, and others (particularly payers) to change their practices in ways that will lead to better healthcare outcomes and lower healthcare costs. CPGs could also prevent litigation for alleged negligent care (5), although this outcome is by no means assured (6). The potential benefits of CPGs are summarized in Table 1.
The potential benefits of clinical practice guidelines
In order to develop an evidence-based medicine (EBM)-based CPG, certain conditions need to be met. The first is that a sufficient quantity of high-quality evidence exists to serve as the foundation, so that statements can be based on controlled clinical trials rather than expert opinion. The development process must be adequately organized, funded and managed to produce valid and useful statements. The resulting guidelines must then be widely disseminated to, and read and understood by, clinicians, patients and other relevant parties, such that patterns of care and health behaviour are changed appropriately, broadly and intensively. Ultimately, the success of guidelines will be judged by cost-effective improvement in health outcomes. Some of the key factors required to achieve these conditions are listed in Table 2.
Desirable attributes of clinical practice guidelines
The concept of CPGs has often been met with enthusiasm. This has stimulated cross-fertilization of ideas between medical specialties, which prevents the process from being dominated by groups with a narrow interest. Domination by one group can result in conflicting guidelines that are not always suitable for use in primary care. Reduced physician autonomy (‘cookbook medicine’) and primary physicians concerned with cost-containment (7) are other problems. If CPGs are not evidence based or validated, they could lead to ineffective or even inappropriate recommendations.
EBM CPGs for chronic headache management for primary care physicians have been developed in many countries. Their objectives include: demonstrating how to make a diagnosis, recommending what medications to use, what to use when the medications do not work, and when it is appropriate to refer the patient to somebody with greater expertise. Why then did a systematic review of 13 studies on CPG use in primary care published up until the end of 1995 find little evidence of their benefit in terms of healthcare outcomes (8)? Could it be because CPGs are poorly disseminated and implemented, which clearly limits their impact (9)?
What are the barriers to guideline utilization and dissemination? In this issue of Cephalalgia, Bianco et al. (10) discuss EBM and headache patient management by GPs in Italy. Their study explored the awareness of technical terms used in EBM and migraine patients’ treatment behaviour among a random sample of 500 GPs. Their mailed questionnaire included questions on demographics, practice characteristics, awareness of EBM, sources of information about migraine and EBM, and patients’ treatment behaviours. Surprisingly, only 27.2% of GPs agreed that clinical trials are needed to evaluate the efficacy of treatments. Awareness of this need was higher in those who learned about migraine from scientific journals or continuing education courses and attended courses on EBM. Disability was equivalent to illness diagnosis for two-thirds of GPs. This belief was more common in those who agreed that clinical trials are needed to evaluate the efficacy of migraine treatments and that the approach to migraine requires evaluation of clinical effectiveness than in those who treated a lower number of headache patients, who were older, and who did not use guidelines. Most (93.1%) GPs felt that it is important to integrate clinical practice with the best evidence available. This behaviour was more frequent in those who agreed that the clinical approach to migraine requires a clinical effectiveness evaluation and that clinical trials are needed to evaluate the efficacy of migraine treatments and in those who attended EBM courses. However, this is in contrast with the result that when scientific evidence indicates that a current treatment is less efficacious or more expensive than the new treatment, respectively, only 14% and 3.1% of GPs would modify the treatment. The authors concluded that training and continuing educational programmes on EBM and headache CPGs for GPs are strongly needed.
Despite an overall positive attitude toward evidence-based diagnosis, the GPs participating in this study were not aware that guidelines were the most favoured approach for moving from opinion-based medicine to EBM. Less than half (46.7%) of the GPs modify the treatment when and if new scientific evidence indicates that it is less efficacious than the new one. What can be done to correct this situation? Education alone may not be enough. Monitoring physician behaviour against practice guidelines may be an answer.