Guidelines are written,but are they followed?

Clinical practice guidelines are statements that include recommendations intended to optimize patient care, which are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.^1,2 Guidelines are widely published, increasing in number and aim to standardize practice based on best available evidence. They should assist decision-making by clinicians and patients about appropriate healthcare for specific clinical situations and are written for a variety of reasons, including: clarification of areas of confusion or controversy, increasing efficiency and streamlining pathways. However, the real purpose of guidelines is to improve patient care and outcome though in reality it is very difficult to measure this specific effect.

Inappropriate requests for tumour markers, perhaps in contrast to many other analytes, have a very tangible impact on patient care both when they are used for diagnosis or case-finding and disease monitoring. It is easy to appreciate the patient anxiety surrounding an unknown diagnosis or whether a malignant disease is responding to treatment. Moreover, the impact of false-positive tests, inappropriate requests and the downstream consequences of these have only undergone limited study,^3,4 which may explain why tumour marker requests are still widely available and seldom vetted.

It is therefore of no surprise that guidelines on tumour marker requesting are extensively written, and a PubMed search of ‘tumour markers’ filtered for guidelines reveals ∼200 hits. In addition multiple articles in mainstream medical journals have tried to address the issue.^5,6

The article by Schulenburg-Brand et al. in this issue ⁷ investigated the impact of local guidance on tumour marker requesting within a single surgical department. They found a significant rate of inappropriate requesting, underpinned by an apparent lack of test knowledge (for example, CA-125 in men and multiple tumour marker panel requests). There was a significant improvement following guideline implementation, though a degree of inappropriate requesting persisted on re-audit. This, like so many other audits of adherence to guidelines raises important questions.

What are the barriers that prevent practitioners from following guidelines?

The failure of uptake of guidelines is a problem that transcends all specialties and sectors of care. Cabana et al. in a systematic review ⁸ of factors affecting guideline compliance, identified 10 broad barriers (see Table 1) which were repeatedly cited as explanations. The lack of awareness, familiarity and agreement with guidelines were cited most commonly in the studies reviewed. This review pre-dates the exponential rise in guideline numbers, and now it seems likely that one other key barrier is the sheer number of guidelines that exist on any single medical issue. In this era of evidence-based practice it can be difficult for an individual clinician to know which guidance to follow. This is somewhat circumvented by guidance being issued at a hospital level, but even within a hospital, practices may vary. At each level it is possible that guidelines from a different source are issued, or equally new guidelines may be written.

Table 1.

Ten broad barriers to guideline adherence as outlined by Cabana et al. ⁸

1.	Lack of awareness of guideline existence
2.	Lack of familiarity with guideline content
3.	Lack of agreement with a specific guideline
4.	Lack of agreement with guidelines per se
5.	Lack of self-efficacy in following guidelines
6.	Lack of expectation about positive outcome from following guidelines
7.	Inertia of previous practice
8.	External barriers – guideline contradictory/difficult to follow/use
9.	External barriers – patient reluctant
10.	External barriers – financial, practice constraints, lack of time.

What is the definition of guideline implementation?

It is clear that simply writing a guideline and publishing it does not amount to it being ‘implemented’. Davis and Taylor-Vaisey ⁹ addressed this issue in a systematic review exploring the translation of guidelines into practice. They classified and defined translation into phases of adoption, diffusion, dissemination and implementation.

With these definitions in mind, it seems likely that more often than not, true guideline implementation fails. Therefore, despite the number of guidelines continuing to steadily rise, without a measure of implementation, these efforts are failing to deliver a true improvement in patient outcome. Targeting the right audience is key on many levels, be it to ensure implementation of guidelines, or the driving force behind the production of guidelines. ¹⁰

How can we promote guideline adherence?

The key point is to identify the barrier. In most cases as outlined in Table 1, this will be lack of awareness or familiarity with the guideline. As in the article published in this issue, the inappropriate requesting of tumour marker panels, and sex-specific tumour markers suggests an underlying lack of awareness and knowledge.

Greco and Eisenberg ¹¹ identified several initiatives to promote changes in physicians’ practice, which can equally be applied to guidelines, including education, feedback, involvement of physicians (many drivers of change come from external parties/management), administrative interventions and financial incentives.

These factors need to be addressed at a local level, if necessary through mandatory e-Learning for clinical staff, or through repeated visual reminders. ¹² At a national level, the Pathology Harmony initiative has produced bookmarks with a summary of national guidance on tumour markers. ¹³ Additionally, the National Audit Committee of the Association for Clinical Biochemistry and Laboratory Medicine has provided laboratory guidelines on tumour markers. ¹⁴ Whether these will be effective remains to be determined, but they are certainly a step in the right direction.

One has to assume that any individual clinician will strive to practice in an evidence-based manner, and providing they know about the guidelines and are familiar with them, will implement them. In practice, evidence suggests that practitioners are more likely to follow guidance if this is being audited or monitored.

What is the lesson for laboratory practice guidelines?

The successful implementation of laboratory guidelines is even more of a challenge as they often require wider dissemination to multiple specialties and grades of clinical staff in both primary and secondary care. Therefore, inadequate targeted dissemination and education is probably one of the key barriers and when the correct audiences are engaged at the outset, implementation can be seamless. ¹⁰

In some respects successful implementation of guidelines and strategies for effective demand management overlap considerably. It is likely that from a laboratory perspective, electronic decision support tools at the time of requesting, restriction of test availability (as in the article in this issue) and more sophisticated computerized physician order entry tools will be most effective in ensuring adherence to guidelines and therefore optimal requesting.

Summary

The number of guidelines produced on laboratory-based topics or otherwise is likely to continue to rise. The authors of these guidelines, their providers and those disseminating them at local level, have a responsibility to consider and/or incorporate an effective implementation strategy. This will undoubtedly involve audit of current practice and the identification of barriers to implementation, such as outlined in the study in this issue, as simply publishing them on the hospital intranet is not adequate. Regular audit with input from key clinical team members and development of local strategies to aid implementation will be key.

Guidelines should be written, and published, but it is imperative that thought be given to how they will be implemented, as this is the key to ensuring a positive impact on patient outcome.