Local clinical guidelines: description and evaluation of a participative method for their development and implementation

BACKGROUND: National guidelines are rarely followed by immediate changein clinical behaviour. We present our experience of an activeeducational method for local development and implementationof a guideline. OBJECTIVE: To evaluate the effectiveness of a participative method fordeveloping local clinical guidelines. METHODS: A trial in a district of the effect of guideline developmentincorporating active participation of intended recipients onsubsequent relevant prescribing. It was carried out in WirralFamily Health Services Authority district (the Wirral peninsula)comprising 69 general practices covering a population of 345763. An exemplar guideline on ‘hypertension in the elderly’was developed by the method described. The principal recommendeddrug was bendrofluazide 2.5 mg once daily. The differences inprescribed daily doses (PDD) of bendrofluazide 2.5 mg tabletsper quarter per 1000 prescribing units (age-weighted population)between the intervention district and England as a whole wasmeasured. RESULTS: Comparison of the intervention district with England data demonstratesa median difference of 122.49 PDD before and 206.34 PDD afterguideline production, this change is statistically highly significant(Mann-Whitney two-tailed P < 0.0001; 95% CL = 36.51–104.77).Grouped regression analysis shows no significant difference(0.89) in slope gradients before guideline production (P = 0.35,95% CL = –3.97–5.76), but the difference in slopegradients after (12.95) is statistically highly significant(P < 0.0001; 95% CL = 8.17–17.73). The data suggeststhat the change in clinical behaviour persisted for at leasttwo years. CONCLUSION: Participation of intended recipient general practitioners andlocal specialists in the development of a guideline by an activeeducational method as described was followed by a favourablechange in clinical behaviour which persisted for at least twoyears. Keywords. Clinical guidelines, development, evaluation, implementation, participation.