  |
|
|
||||
|
||||||
| Journal of the New Zealand Medical Association,
06-August-2004, Vol 117 No 1199
|
||||||
|
Clinical practice guidelines’ development and use in
New Zealand: an evolving process
Eileen McKinlay, Deborah McLeod, Antony Dowell, Catherine
Marshall
New Zealand (NZ) guideline development began around 1992
with various organisations funding guidelines on specific topics. In 1996, the
New Zealand Guidelines Group (NZGG) was formed. This initiative was funded by
the National Health Committee and based on the guideline development processes
introduced by the Seattle Group Health
Co-operative.1 The first initiative involved
establishing a number of fellowships (for opinion leaders from a broad spectrum
of clinical and consumer interests) to study guideline development in Seattle.
Later, US and other international guideline developers were invited to NZ to run
intensive training courses. The NZGG became one of the founders of the
Guidelines International Network, which shares ‘evidence’
internationally.
Guidelines were seen as a way of introducing and promoting
evidence-based practice. New Zealand government directives support the use of
evidence-based practice and clinical practice
guidelines.2,3 The original aim of the NZGG
guidelines programme included formally training medical practitioners to
undertake guideline development, and for these clinicians to develop
evidence-based guidelines using the prescribed development process. An
anticipated outcome was a movement towards an explicit evidence-based approach
to health care provision (Figure 1).
Figure 1. Continuum of clinical
decision-making
 Since then, clinicians from other disciplines (nursing,
social work, community health workers, mental health workers, occupational
therapists, and disability sector workers), consumers, and cultural
representatives have undertaken guideline development training and been involved
on guideline development groups.
General practitioners are considered an important target
user group for the New Zealand guidelines that have been developed to date.
Early NZ guidelines were often printed in full and disseminated by post to GPs
throughout New Zealand with no other form of implementation. Although there is
considerable international research literature regarding barriers to guideline
uptake by doctors including general practitioners (GPs), little research has
been undertaken in NZ.
Internationally, research literature identifies that there
are barriers to the adoption and use of guidelines; including those guidelines
that originate from the doctor4 or the
structure they work in; or due to patient-related
factors.5 Some doctors are hesitant to use
guidelines; they are suspicious both of the
philosophy6 and reasons behind
them,7,8; and the content of the guidelines
themselves.9 Whilst the literature strongly
supports consumers’ using guidelines to inform themselves and their
care,10 the impact and actual use of guidelines
by consumers has not been evaluated.
Although many studies have been undertaken on
implementation, and although universally it is agreed that implementation is
pivotal in ensuring guidelines are used, there is no clarity about the most
effective implementation
methods.11–14
In NZ, Thornley et al15
examined the effectiveness of postal dissemination of evidence-based guidelines
on heavy menstrual bleeding. Prior to updating the recommendations on heavy
menstrual bleeding, Park and Farquhar surveyed NZ GPs and gynaecologists
regarding their current practice in treating heavy menstrual bleeding as well as
perceived barriers to the recommendations of the 1998
guidelines.16
Arroll et al determined the reported use and perceived
usefulness of four national guidelines by New Zealand
GPs.17 Factors included targeted clinician
education following dissemination, availability of the recommendations, and
accessible decision support through the
Adis
New Ethicals (drug information)
Catalogue.
Wynn-Thomas et al18 in
their study of the use of the Ottawa ankle rules, surveyed NZ GPs about their
use of selected New Zealand and international guidelines. GPs reported they
‘hardly ever’ or ‘never’ used guidelines in clinical
practice. The effectiveness of the dissemination of the
New Zealand Guidelines for the Diagnosis and
Treatment of Adult Asthma was examined by Martin and
Reid.19 Although guidelines were being
(routinely) sent to all GPs; 2 weeks after it was sent, almost one-third of GPs
could not remember receiving it.
In 2004, 46 guidelines have been posted in the NZGG
guideline library, available on http://www.nzgg.org.nz In addition to NZGG
sponsored guidelines, other independent guideline-developers continue to develop
or update guidelines; many of these guidelines are also available on the NZGG
website.
Primary care clinician acceptance and use of guidelines has
been limited, and anticipated changes in clinical practice have not yet
occurred. This study aimed to explore the barriers to guideline use by NZ
general practitioners and to develop strategies to overcome identified barriers.
MethodsTo gather information about
guidelines and the use of guidelines by New Zealand clinicians, a literature
search was undertaken. A literature review reference document was developed
after searching for guidelines literature from the main
databases—including Medline, Embase, CINAHL, and psycINFO. The review
summarised the key themes from the available
literature.20 Few NZ published or unpublished
works were located. Any (unpublished) projects undertaken to evaluate NZ
guidelines were identified and audited.
A purposeful sample of currently practicing New Zealand
general practitioners (GPs)—representative of age, gender, years in
practice, and urban/rural status—were invited to take part in this
project. A purposeful sample of guideline stakeholders were invited to nominate
a representative to be interviewed. Stakeholders included the NZGG, the Ministry
of Health (MOH), the then Health Funding Authority (HFA, a health service
purchaser now devolved into the MOH), PHARMAC (the New Zealand pharmaceutical
regulator), and an Independent Practitioner Association (IPA, an organisation of
GP providers).
Interview schedules were developed in collaboration
with stakeholders. Schedules included open-ended questions about knowledge and
use of existing guidelines; the role and importance of guidelines; and
additional questions for GPs concerning their use of guidelines, perceived
barriers and facilitators to the use of guidelines, and perceived consumer use
of guidelines or other evidence-based information. Interviews were generally
undertaken by one researcher in 2000/2001 and were either face-to-face, or via
email or telephone if a face-to-face interview was not possible. Interviews were
audio-taped and transcribed. GP interviews were continued until data saturation
was reached.
Data from interviews were analysed using inductive
thematic analysis, identifying themes either held in common or disparate between
those interviewed, and themes that coincided or were different from the
literature. Emerging themes were discussed by the research team. The results
were presented to the NZGG Board and strategies were developed to address a
number of issues identified from the data.
In collaboration with the Department of General
Practice at Wellington School of Medicine and Health Sciences, strategies were
identified, and a number of initiatives have since been undertaken by the NZGG
to enhance end-user acceptance of guidelines. In addition, the research team
developed a guideline evaluation framework21
based on the AGREE model.22
ResultsFive stakeholder organisations were
asked to nominate a representative for interview, and 13 currently practicing
general practitioners (GPs) were approached to be interviewed. All those
approached, agreed to participate. GPs ranged in experience from a newly started
practitioner through to one nearly retiring. They were representative of urban
and rural practice and from both the North and South Islands.
At the time the interviews were undertaken, NZGG was an
evolving organisation. A new full-time Chief Executive had been appointed, and
several guidelines were ‘in production’. The reason for wanting to
foster development of guidelines included ‘having assurance of a robust
process to determine the evidence around the relative efficacy of clinical
treatments’ and to ‘ensure that the general public were receiving
interventions or services that would be of maximum benefit’. It was also
hoped that guidelines could be used to advocate for access to the most effective
forms of treatments (including cost effectiveness), even if sometimes this could
require changes in prescribing regulations and pharmaceutical schedule funding.
(NZGG believed that guideline development and use would contribute to a cultural
shift over time towards the use of research evidence in clinical
practice.)
The HFA believed guidelines had the potential to improve
overall care, including the provision of consumer information, thus giving
patients an expectation of care delivery. The HFA viewed the NZGG as an
independent body with expertise and networks.
The MOH believed that evidence-based guidelines were one of
a range of tools which could be used to enhance the appropriate quality and
standards of the health service. The MOH believed that they should be
responsible for creating an environment where guidelines were seen as useful
tools. However, they did not believe it was their role to develop structural
processes or to sponsor implementation of a specific quality improvement method
to enhance guideline usage.
PHARMAC perceived NZGG’s main role as the development
of evidence-based guidelines, and supported the use of guidelines in general,
particularly those which met their funding/affordability objectives. The
development of evidence-based guidelines appeared to influence funding decisions
that PHARMAC made. However, PHARMAC recognised there was an inevitable tension
when guidelines were released containing pharmaceutical recommendations that
PHARMAC could not fund, or when there was a lag time in funding a guideline
pharmaceutical recommendation.
At the time of interview, the IPA had no formal interfaces
with the NZGG. They believed that ideally they should have an interface with the
NZGG and identify clinical practice issues for consideration as guideline
topics. IPAs had developed their own guidelines and education/implementation
strategies for members, which they felt were effective. They noted that general
practitioners preferred to use locally developed IPA guidelines, possibly
because of their involvement in development and recommendation of services
available locally.
New Zealand GPs’ use of (and attitudes to) guidelinesThe key themes (to emerge from
interviews with GPs) related to GP recognition of guideline formats; stakeholder
endorsement; prioritisation of guideline development; GP information overload;
guideline implementation issues; the relevance of guideline recommendations to
general practice; and GP participation in guideline development
groups.
GP
recognition of
guideline
formats—Visual recognition
of guideline documents within NZ appeared to be low with confusion between
evidence-based guidelines and quasi guidelines or other information produced and
disseminated to GPs by drug companies or interest groups.
Stakeholder
impact—Endorsement by professional colleges or other professional
networks was perceived to have a positive influence on the recognition and
possible uptake of guidelines. Conversely, influence by Government or other
health regulatory organisations was viewed negatively. GPs expressed concern
that guidelines could be linked to contracts and that failure to comply with
guidelines may have medicolegal implications.
Guideline development
prioritisation—GPs were uncertain whether current NZGG guidelines
met their need for evidence-based information, and believed the process of
prioritising topics for guideline development was unclear. Furthermore, they
believed that they needed to be involved in this prioritisation process through
GP organisations (such as IPAs).
Information
overload—The GPs reported that they were overwhelmed by the written
material sent via post and electronically—with some Wellington GPs in 2000
having to read as much as 52 pieces of postal mail per day (excluding
email).23 Newly arrived guidelines have to
compete with patient-related and other essential information. GPs also reported
difficulty in establishing effective storage and management systems for hardcopy
guidelines, which inhibited timely retrieval.
Implementation
issues—The interviewed GPs felt that effective implementation was
essential to enhance the uptake of guideline recommendations. They did not feel
that postal dissemination of guidelines (on its own) to GPs had been effective.
Implementation strategies such as working in conjunction with stakeholders to
locally redevelop and implement national guidelines were suggested. Short
education programmes within scheduled GP organisation or peer review meetings
and one-to-one practice education (academic credentialling) were also suggested.
Relevance of guideline
recommendations to practice—Many of the GPs interviewed saw it as
unfortunate that there were several recommendations made within the NZ
guidelines (which were not relevant to their practice or were inaccessible, or
out of the scope of, their practice) thus reflecting a stakeholder objective in
developing the guideline to change policy rather than practice. An example
frequently cited by general practitioners was the recommendation in the
Guidelines for the treatment and
management of depression by primary health
professionals24 to use cognitive behavioural
therapy in the treatment of depression, when this therapy was neither publicly
funded nor freely available. Another example was the recommendation (made in the
Guidelines)
to use tranexamic acid for the management of heavy menstrual
bleeding25 when, at the time the
Guideline was released (and for some
time after), this medication could only be prescribed by a specialist
gynaecologist or obstetrician.
GP participation in
guideline development groups—GP participation in guideline groups
was viewed as onerous because of the time commitment involved through
undertaking guideline development training, meeting time, and work required in
between meetings. For GPs who had never been involved in guideline development,
there was a perceived lack of GP involvement in guideline development teams, and
(when GPs were known to be involved) a lack of a defined process for GP
selection. GPs felt they were not consulted whilst the guideline was being
developed.
Implications: NZGG initiatives to address barriers to guideline useStrategy
to ensure recognisability of NZGG guidelines—A uniform and
recognisable appearance/brand has been developed for guidelines sponsored by the
NZGG. Documents now routinely include abbreviated formats and consumer
information. The NZGG logo is prominently displayed along with the logos of
supporting organisations and professional bodies. This allows practitioners to
easily differentiate between NZGG guidelines and guidelines developed by
specific interest groups, therefore providing quality assurance.
Strategy to identify
stakeholders—NZGG has established strong links with appropriate
stakeholders to ensure goals are congruent and acceptable to guidelines
end-users. Stakeholders nominate members to the guideline development teams, and
are invited to peer review draft guidelines and comment on the penultimate
version of the guidelines as part of the formal endorsement process.
Strategy to address
guideline development priorities—The NZGG attempts to closely
monitor possible need for guideline development though contacts with their
funding bodies. To a large degree, the priority topics have been driven by the
NZ Health Strategy26 or those areas where the
greatest gap between current practice and evidence-based practice has been
perceived. NZGG is working with the Ministry of Health to set up a process for
liaising with stakeholders to discuss priorities for the future, although there
is no guaranteed funding for priority area guideline development.
Strategy to address the
need for appropriate information—The NZGG are attempting to provide
additional print and electronic formats that enhance different reading styles.
Summary sheets are available in hard copy and electronic format. Online access
is available, and some IPAs are providing GPs with the NZGG guidelines and other
information on CD-ROM.27 NZGG are now producing
several information resources for consumers and other provider groups.
Strategy to address
guidelines implementation issues—NZGG strongly supports the
implementation of guidelines, and now requires guideline-development groups to
also develop an implementation strategy. However, they acknowledge their
dependency on funders to also support implementation. (In the past there has
been no mandate for funders to routinely implement new guidelines.) Currently,
several Primary Health Organisations (PHOs) are using the guidelines to build
their primary care preventative programmes. In addition, other organisations
such as IPAs, the Best Practice Advocacy Centre (BPAC), and the Goodfellow Unit
(Department of General Practice and Primary Health Care, University of Auckland)
have used the guidelines as base resources to develop CME programmes.
Since 2001 implementation strategies have been increasingly
tailored according to the guideline topic and the end-user population. At
regional and national meetings of healthcare practitioners, NZGG actively
promote the main messages from guidelines.
A typical implementation strategy targeting GPs might now
include: dissemination by post (in conjunction with material known to be read by
GPs such as the biweekly medical newspapers); wide national and medical media
coverage of the recommendations; PHARMAC- and District Health Board-funding
(aimed at raising awareness of evidence-based strategies); development of a
brief laminated guideline summary; guideline promotion at the RNZCGP or similar
conferences; working with Consumer magazine to produce an article on the
guideline recommendations for consumers; commissioning a patient-information
resource; and running Continuing Medical Education (CME) sessions and sponsoring
online CME .
Strategy to ensure there is
relevance of guideline recommendations to clinical
practice—Guideline-development groups now liaise with the Ministry
of Health and other regulatory bodies (including Medsafe and PHARMAC) throughout
the guideline-development process. Guideline-development teams are also asked to
provide practical guidance to readers where there may be treatment or care
options that are not affordable or accessible in NZ, and to make recommendations
that are suited to the current NZ setting. Guidelines are also
‘road-tested’ before publication and when any impractical
recommendations are identified, these are reviewed, and action is taken (where
possible) to see if systemic changes can be encouraged to bring effect to the
recommendations.
Strategy to address the
involvement of GPs in guideline development teams—An independently
appointed NZGG project manager now supports each development group. As many
aspects of the guideline development process as possible are transparent, with
guideline members disclosing vested or competing interest. Critical appraisal of
literature relating to a clinical topic is now generally being undertaken by
expert researchers rather than the development group themselves (which happened
in the past). The NZGG has formulated a new evidence-grading system to include
high quality qualitative research. This approach is important to enable the
inclusion of evidence from cultural groups
There is now greater flexibility in timelines for guideline
development, recognising that some clinical topics are complex to address.
Generally speaking, NZGG are trying to speed up production of guidelines by
taking the main bulk of the work away from the guideline-development team
members. For example, clinicians are now routinely nominally paid for work
undertaken in guideline development groups.
DiscussionSince 1998 and the formation of the
NZGG, increasing numbers of guidelines have been developed and disseminated for
clinicians to use. The NZGG has fostered a robust, internationally recognised,
evidence-based guideline-development process; and has rigorously protected the
process.
There have been few evaluations of the impact and outcomes
of guidelines produced and disseminated to New Zealand GPs. Those evaluations
which have been undertaken suggest that the impact of guidelines has not been as
substantial as hoped for.
Whilst there appears to be adequate knowledge around, and
processes to undertake development of, ‘evidence-based’ guidelines;
there has been a considerable knowledge-gap regarding the attitudes of NZ
clinicians towards and current use of guidelines—including which guideline
formats and implementation methods work best for NZ clinicians and consumers.
This qualitative review of the New Zealand guidelines
movement has identified a number of issues impacting on guideline use by GPs.
However, there are limitations in this study. The size of the sample may limit
generalisability, and qualitative methods identify the range of opinion rather
than the proportions of stakeholders who hold any given attitude. Nevertheless,
the themes reported here recurred independently across interviews, and are
consistent with international writing on guidelines.
New Zealand guideline-development appears to have been
predominantly funder- rather than clinician-driven and this may have influenced
the acceptability of the guidelines to GPs. Funders have initiated
guideline-development for various reasons, primarily based on the need to close
a perceived gap between current practice and evidence-based practice but also as
a mechanism to drive policy changes. It is unfortunate that currently there is
no formal mechanism for GPs to signal the need for guideline development on a
particular topic.
Use of guidelines in the past to drive policy changes has
lead to the inclusion of recommendations for pharmaceuticals and treatments that
cannot be accessed by GPs—this has caused frustration for GPs. Lack of
early liaison with stakeholder/regulator groups (including PHARMAC and the MOH)
has exacerbated these issues. In addition, there is ongoing dialogue about
whether recommendations (which promote interventions that are not available in
NZ) should be included in a NZ guideline, even if they are recommended as
‘best’ practice.
In New Zealand, previously there has not always been a
formal estimation of current practice prior to guideline-development, and
clinical topics have been identified as priorities for guideline development
without having this baseline information. Therefore it has been unclear whether
NZGG guidelines have been effective in closing the gap between current- and
evidence-based practice, or whether in fact the gap exists as a result of lack
of knowledge of best practice or as a result of resource constraints or other
factors.
NZGG have recently worked more closely with stakeholders in
planning an overall guidelines strategy. Involving organisations such as the
Royal College of General Practitioners and GP organisations potentially
increases guidelines relevance for GPs. It is unfortunate that some early NZ
guidelines were not well received by clinicians because of their format and/or
their recommendations, and clinicians may have become averse to considering
recently released guidelines. NZGG now informs stakeholder groups about any
guidelines work in progress, and notifies them when to expect the release of new
guidelines. This means that CME events can be arranged in advance.
Unfortunately, the volume of guidelines being sent to GPs is still substantial
(5 guidelines were released in 2002; 7 guidelines, 16 summaries and 1 evidence
report completed in 2003, and 7 guidelines and 7 summaries anticipated to be
completed in 2004). Thus, some mechanism whereby GPs can prioritise new
guideline information and can request selected evidence summaries is still
required.
In the past, there has not been a systematic process to
implement guidelines in New Zealand. Guideline development groups have not been
routinely funded to develop an implementation strategy and no single body has
held responsibility to ensure implementation was occurring. Although guidelines
are formally launched and disseminated by post to practicing clinicians, and
some may receive media and other attention at the time of release, generally
there is no ongoing formal implementation.
There is a substantial body of international literature on
implementation, including literature that is specific to primary
care.28–30 In summary, studies of
guideline implementation have demonstrated that, despite positive attitudes
towards guidelines,9,31 there is variable to
low usage.9,32,33 However, the potential
perceived by stakeholders (for guidelines to provide an effective vehicle for
disseminating new information) drives continuing examination of different
implementation strategies.
Meta-analyses and reviews conclude that different
implementation interventions are effective under some circumstances, but none is
effective in all circumstances.34–37
Implementation strategy must be planned, tailored to specific barriers to
change38 and targets
set.39
Although NZGG undertake the Agree Collaboration process for
evaluating the rigor of guideline development, this model does not incorporate a
formal evaluation of the effectiveness of dissemination and implementation. A
model developed by the research team (based on the Agree Collaboration model)
also includes an evaluation of the guideline topic selection process and the
effectiveness of dissemination and
implementation.21
In the 2 years since this data was collected, and in
response to the project recommendations (based on international guideline
research), the NZGG has actively attempted to address clinician barriers to
using guidelines by various measures described above. There is a further
commitment to addressing clinician barriers through implementation and by
working more closely with practicing clinicians to determine professional needs
that can be met by guideline development.
Author information:
Eileen McKinlay, Lecturer in Primary Health Care, Department of General
Practice, Wellington School of Medicine and Health Sciences, Otago University,
Wellington; Deborah McLeod, Research Director, Department of General Practice,
Wellington School of Medicine and Health Sciences, Otago University, Wellington;
Antony Dowell, Professor and Head of Department, Department of General Practice,
Wellington School of Medicine and Health Sciences, Otago University, Wellington;
Catherine Marshall, Chief Executive, New Zealand Guidelines Group Inc,
Wellington
Acknowledgements: We
acknowledge the funding and support of the New Zealand Guidelines Group; and we
also thank the study participants.
Correspondence:
Eileen McKinlay, Lecturer in Primary Health Care, Department of General
Practice, Wellington School of Medicine and Health Sciences, Box 7343,
Wellington South. Fax: (04) 385 5539; email: emckinlay@wnmeds.ac.nz
References:
|
|
||||
| | Current
issue | Search journal |
Archived issues | Classifieds
| Hotline (free ads) Subscribe | Contribute | Advertise | Contact Us | Copyright | Other Journals |
|