The practice guideline 'Diabetes mellitus type 2' (second revision) from the Dutch College of General Practitioners; a response from the perspective of general practice

The publication of the practice guideline 'Diabetes mellitus' by the Dutch College of General Practitioners in 1989 marked the start of an era of publication of several guidelines that helped general practitioners using evidence-based medicine in clinical practice; the guidelines also helped to teach students. The second revision of this guideline presents many improvements, especially simplifications in the medication-schedules. However, the new recommendation to use thiazolidines is based on only one large study and has some unpractical aspects. The new guidelines do not mention preventive action, nor advice regarding early detection. Clinical practice has changed in recent years with the introduction of nurses specialising in diabetes and, despite published research on this subject, the guidelines do not give any recommendations for this. What is also missing are national clinical guidelines for doctors specialising in internal medicine. When patients do not respond to treatment according to the general practitioners' guidelines and are referred to a specialist in internal medicine, the treatment is diverse and seems to be doctor-dependent. It is important that treatment there be standardised as well so that general practitioners can refer more effectively.     

Towards evidence-based general practice in rural and remote Australia: an overview of key issues and a model for practice

There is an extensive global move towards evidence-based practice intended to increase the quality and effectiveness of health care. However there are barriers and issues when rural general practitioners attempt to incorporate evidence-based medicine in their practice. Key issues affecting the uptake of evidence-based medicine by rural general practitioners include the gaps in the scientific evidence relevant to general practice, time limitations, and the cost of Internet access, geographical isolation from centres of evidence-based practice and limited training opportunities. General practitioner consultations may involve multiple, ill-defined problems and the patients' views about their treatment may conflict with an evidence-based treatment approach. Rural general practitioners may require additional supports to access information from research through Internet-based resources, accessible summaries of evidence or clinical practice guidelines. In addition a model to assist rural general practitioners use evidence-based medicine is suggested. This model may enable the clinical decision-making process to integrate clinical experience, patient preferences and an understanding of the rural context of practice with the best available evidence, to in turn produce best practice.     

The attitudes of Australian GPs to evidence-based medicine: a focus group study

BACKGROUND: Over the last 6 years there has been an exponential increase in the publication of medical literature on evidence-based medicine. In Australia, as in many other parts of the world, there have been calls for an increase in the practice of evidence-based medicine. In general practice, two major themes of criticism have been the lack of relevant research evidence in primary care and the failure of evidence-based medicine to take into account the complexity of the consultation. OBJECTIVE: We aimed to explore the attitudes of Australian GPs to evidence-based medicine. METHODS: We conducted a qualitative study using evidence-based guidelines as a model to explore attitudes within focus group interviews. Focus group data were analysed using grounded theory methodology. The study was set in the Australian cities Melbourne, Adelaide and Darwin. The subjects were 27 GPs in five focus groups. RESULTS: Data were used to generate a model illustrating factors affecting the consideration and use of evidence within consultations. Prior beliefs and experience had a strong influence on decision-making. Overall, the GPs had a positive attitude to evidence-based medicine and stated that this could be a helpful strategy for meeting their information needs. These needs arose during the consultation and were frequently generated by patients. The evidence-based approach was regarded as particularly useful when patients required validation of their management or had specific queries. However, the GPs also expressed some concerns, such as the application of evidence from clinical trials to individuals, and the appropriateness of using research evidence with certain patients. They also feared a move away from the 'art of medicine'. None of the GPs expressed a need for critical appraisal skills. CONCLUSIONS: The Australian GPs in this study had mixed views about the increasing profile of evidence-based medicine, and the use of this paradigm in practice. Acceptability was more likely to be influenced by relevance to general practice and local contextual and patient factors than by the strength, or critical quality of the evidence.     

Whither our art? Clinical wisdom and evidence-based medicine

The relationship between evidence-based medicine (EBM) and clinical judgement is the subject of conceptual and practical dispute. For example, EBM and clinical guidelines are seen to increasingly dominate medical decision-making at the expense of other, human elements, and to threaten the art of medicine. Clinical wisdom always remains open to question. We want to know why particular beliefs are held, and the epistemological status of claims based in wisdom or experience. The paper critically appraises a number of claims and distinctions, and attempts to clarify the connections between EBM, clinical experience and judgement, and the objective and evaluative categories of medicine. I conclude that to demystify clinical wisdom is not to devalue it. EBM ought not be conceived as needing to be limited or balanced by clinical wisdom, since if its language is translatable into terms comprehensible and applicable to individuals, it helps constitute clinical wisdom. Failure to appreciate this constitutive relation will help perpetuate medical paternalism and delay the adoption of properly evidence-based practice, which would be both unethical and unwise. This revised version was published online in July 2006 with corrections to the Cover Date.     

The development of evidence-based clinical practice guidelines. Integrating medical science and practice

Practice guidelines are rapidly becoming preferred decision-making resources in medicine, as advances in technology and pharmaceutics continue to expand. An evidence-based approach to the development of practice guidelines serves to anchor healthcare policy to scientific documentation, and in conjunction with practitioner opinion can provide a powerful and practical clinical tool. Three sources of information are essential to an evidence-based approach: a) an exhaustive literature synthesis; b) meta-analysis; and c) consensus opinion. The systematic merging of evidence from these sources offers healthcare providers a scientifically supportable document that is flexible enough to deal with clinically complex problems. Evidence-based practice guidelines, in conjunction with practice standards and practice advisories, are invaluable resources for clinical decision making. The judicious use of these documents by practitioners will serve to improve the efficiency and safety of health care well.     

The new CBO-guideline 'Osteoporosis' is a broadly supported standard for clinical practice

The Dutch Institute for Health Care Improvement (CBO) has published new (revised) guidelines for the screening and case-finding of osteoporosis and for its prevention and treatment. During the last few years, two other guidelines have been published by the Dutch College of General Practitioners and the Dutch Health Council, respectively. The CBO guideline would seem to reflect the current views on clinical practice the best and is supported by all the relevant medical specialist communities. Screening of the general population is discouraged, whilst case-finding is recommended with selected patients. Compared to the 1999 standard of the Dutch College of General Practitioners, this new consensus offers more possibilities for the preventive treatment of patients with possible osteoporosis and the treatment of patients with the disease. In the first years after menopause, treatment with oestrogens (combined if necessary with progestagens), tibolone and selective oestrogen receptor modulators may be considered. Treatment with bisphosphonates is advised in persons who are being or will be treated with corticosteroids, postmenopausal women with one or more osteoporotic fractures, or men and women with an increased risk and a T-score below -2.5. The CBO guideline constitutes the current standard for clinical practice with regard to osteoporosis. There would appear to be no need for a revision of the other guidelines.     

Occupational physicians' perceived value of evidence-based medicine intervention in enhancing their professional performance

OBJECTIVES: This study evaluated how physicians in a nonclinical setting perceive the value of an intervention with multifaceted evidence-based medicine with regard to enhancing their professional performance. METHODS: A qualitative study was conducted using focus groups and face-to-face interviews with 14 of the 48 Dutch occupational physicians who participated in the intervention. The intervention combined a didactic course in evidence-based medicine with recurrent case-method learning sessions. During the sessions, the participants were challenged to discuss their cases and to give one another feedback on how to find information on cases. RESULTS: Five main themes and four subthemes were identified: professional behavior and quality of care (subtheme: transparency): occupational physicians associated being up-to-date with quality of care, and evidence-based medicine was associated with improvements in professional standards; critical attitude and improved recommendations: occupational physicians asked themselves more-profound questions and searched more for information; sharing knowledge: the peer-group sessions facilitated the sharing of knowledge; communication (subthemes: colleagues, clients and other specialists): the more soundly based recommendations enhanced self-confidence positively and therefore altered interaction with medical specialists in particular; and satisfaction and barriers: the occupational physicians were especially content with the structured discussion in the peer-group sessions. However, the intervention was very time consuming. CONCLUSIONS: The participants regarded the intervention as a useful method for enhancing their professional performance. They stated that they became more up-to-date and more self-confident by searching for and sharing knowledge. These actions resulted in more scientifically based recommendations and improved interaction with clients and other specialists. However, time constraints remain an important barrier.     

Qualitative methods and the development of clinical assessment tools

Practitioners are under increased pressure to demonstrate effectiveness and to do so in as short a time as possible. In addition, evidence-based practice calls for practitioners to take into consideration not only best research evidence but also the wants and preferences of patients, and their own clinical expertise. In light of these demands, standardized assessment tools are likely to become increasingly central in clinical practice in a variety of health care fields, such as nursing, social work, psychiatry, psychology, and medicine. In this article, the author uses two case studies to show how qualitative methods can contribute to the development and evaluation of clinical assessment tools that are responsive to contemporary pressures. She also shows that evaluations of clinical instruments are incomplete if they do not include a qualitative component.     

Health policy issues and applications for evidence-based medicine and clinical practice guidelines

Evidence-based medicine and clinical practice guidelines have become increasingly salient to the international health care community in the 1990s. Key issues in health policy in this period can be categorised as costs and access to care, quality of and satisfaction with care, accountability for value in health care, and public health and education. This paper presents a brief overview of evidence-based medicine and clinical practice guidelines and describes how they are likely to influence health policy. Evidence-based medicine focuses on the use of the best available clinical (efficacy) evidence to inform decisions about patient care; guidelines are statements systematically developed from efficacy and effectiveness research and clinical consensus for practitioners and patients to use in making decisions about appropriate care under different clinical circumstances. Both fields have developed methods for evaluating and synthesising available evidence about the outcomes of alternative health care interventions. They have clear implications for health policy analysts: greater reliance should be placed on scientific evidence, policy decisions should be derived systematically, and health care decisionmaking must allow for the active participation of health care providers, policy makers, and patients or their advocates. The methods and information generated from evidence-based guidelines efforts are critical inputs into health policy analysis and decision-making.     

Identifying barriers to the adoption of evidence-based medicine practice in clinical clerks: a longitudinal focus group study

OBJECTIVE: To identify and explore common barriers to the adoption of evidence-based medicine (EBM) practice in the undergraduate setting. DESIGN: Nested longitudinal, focus group-based, qualitative study. Setting The University of Hong Kong Medical School, Hong Kong, China. PARTICIPANTS: A group of 39 Year 4 medical undergraduates who participated in an EBM intervention cluster randomised crossover trial. MAIN OUTCOME MEASURES: Students' attitudes, opinions and perceptions of barriers to EBM use. RESULTS: General attitudes towards EBM and the teaching intervention were positive. Four sets of barriers to greater EBM use were identified as follows. (1) Learning environment including prevailing norms for student learning involving examination-oriented, textbook learning, prior availability of clinical practice guidelines, lack of encouragement from teachers and economy of time by utilising teacher expertise. (2) Limitations of evidence consisting of poor point-of-care access to medical literature, difficulty in locating evidence and the perceived low relevance of overseas evidence to Chinese patients. (3) Lack of opportunity to practise EBM due to lack of continuity of care and anxieties about negative teacher attitudes towards EBM use at the point-of-care. (4) Time constraints such as competing study demands and long evidence search time. CONCLUSIONS: Significant barriers to the successful implementation of EBM learning in the clinical clerkship setting were identified. These can be specifically targeted to ameliorate any inhibition of clinical learning they may impose.     

Evidence-based healthcare and health informatics: derivations and extension of epidemiology

Epidemiology provides extremely valid information and evidence regarding human health.Epidemiologic findings with regard to major illnesses must be amassed, enhanced, and expanded further into related areas as a foundation for evidence-based medicine that is based on clinical practice, as well as for evidence-based healthcare that includes public health-related issues. Epidemiology should be recognized not only by epidemiologists but also by a variety of people, including specialists in other areas for healthcare and medicine, people in law and media, policy makers, and the general public. A system is needed that can create information for facilitating appropriate decision-making with issues related to clinical medicine and public health. The principles and methodology of epidemiology are used as a base for developing a field of health informatics. The objective of health informatics is to establish a system for facilitating the flow and circulation of health and medical information. Health informatics has potential applications for the creation, communication, and use of information, and the discipline is being expanded as a practical applied science in search of solutions. This report represents an effort to expand the scope of health informatics and extend the applications of epidemiology by working with individuals in other disciplines and the public.     

Power and influence in clinical effectiveness and evidence-based medicine

BACKGROUND: The need to base clinical interventions on valid findings of research has been a dominant theme in clinical practice during the last quarter of a century. However, there is much evidence showing that research evidence reaches everyday practice slowly. Solutions to this problem include evidence-based practice and implementation by guidelines and audit. Studies of these methods have included surveys of clinicians' views, implementation projects and evaluations of educational interventions, but they have not examined their implications for the power structure of clinical organizations. This is surprising, given the emphasis placed on medical power in sociological studies of health care. METHODS: A framework derived from management theory defines and summarizes theories of power and influence under the headings: sources of power, overt methods of influence, unseen or covert methods of influence and individual response to influence. This framework is then used to analyse the power and influence possessed and exerted by general practitioners (GPs) and hospital consultants and how these are affected by evidence-based practice and guidelines and audit programmes. OUTCOMES: GPs are seen as having less expert power than consultants and to be more compliant with externally managed guidelines and audit programmes. It is pointed out that compliance with guidelines and audit programmes helps GPs to meet their contractual requirement to be involved in clinical audit activities. Evidence-based practice, which directly challenges the authority of expert opinion is seen as a threat to the power of consultants, but a potential opportunity for GPs and other clinicians whose status is traditionally lower.     

A preliminary study of the decision-making process within general practice

OBJECTIVE: The aim of the present study was to explore the factors that contribute to the process of decision making within general practice, over and above evidence-based information. METHODS: A qualitative study was conducted using semi-structured interviews on a purposeful sample of GPs, based in the South West of England. Each interview was tape-recorded and transcribed verbatim. RESULTS: Five broad categories emerged from the data: practitioner; patient; practitioner-patient relationship; verbal and non-verbal communication; evidence-based medicine; and external factors. CONCLUSION: The nature of general practice is such that the process of making clinical decisions is complex. In an era when GPs are being overwhelmed by evidence-based information, consideration needs to be given to the implications that the nature of the decision-making process has upon the way 'evidence' is constructed and promoted within general practice.     

Pragmatic evidence and textual arrangements: A case study of French clinical cancer guidelines

Both critics and supporters of evidence-based medicine view clinical practice guidelines as an important component of this self-defined “new paradigm” whose goal is to rationalize medicine by grounding clinical decision-making in a careful assessment of the medical literature. We present an analysis of the debates within a guideline development group (GDG) that led to the drafting, revision and publication of a French cancer guideline. Our ethnographic approach focuses on the various aspects of the dispositif (or apparatus) that defines the nature and roles of participants, procedures, topics and resources within the GDG. Debates between GDG members are framed (but not dictated) by procedural and methodological rules as well as by the reflexive critical contributions of the GDG members themselves, who justify their (tentative) recommendations by relating to its (possible or intended) audiences. Guideline production work cannot be reduced to an exchange of arguments and to consensus-seeking between pre-defined professional interests. It is about the production of a text in the material sense of the term, i.e. as a set of sentences, paragraphs, statements and formulations that GDG members constantly readjust and rearrange until closure is achieved. As such, guidelines partake in the emergence and stabilization of a new configuration of biomedical knowledge and practices grounded in the establishment of mutually constitutive links between two processes: on the one hand, the re-formatting of clinical trials into a device for producing carefully monitored evidence statements targeting specific populations and clinical indications and, on the other hand, the increasingly pervasive role of regulatory processes.     

Teamwork in Sri Lankan general practice

This paper reports part of a study to investigate the organizationof general practice in Sri Lanka with particular reference toteamwork. Questionnaires were sent to 347 members of the twobodies representing general practitioners and to a further 43doctors who were identified as providing either traditionalor Western primary medical care in a defined population. A responserate of 74.2% was obtained. All practitioners of traditional(Ayurvedic) medicine were single-handed and 54.4% of membersof the College of General Practitioners in Sri Lanka also workedon their own. All ancillary staff were employed by the practitionerand the mean number of staff was 3.1. Multifactor comparisonwas undertaken. More staff were employed by practitioners whowere under 45 years old, who lived within five miles of a hospital,and who had in-patient facilities. Questions are posed concerningthe development of team care in Sri Lanka.     

The practice guideline 'The STD consultation' from the Dutch College of General Practitioners; a response from the perspective of general practice

The new guidelines from the Dutch College of General Practitioners on sexually transmitted diseases (STDs) replace three existing practice guidelines covering a number of sexually transmitted diseases. In the Netherlands the general practitioner treats almost 75% of all patients with an STD. These include patients with symptoms, patients who are worried or anxious, and patients at high risk of an STD. STD-risk assessment should be regarded as a high priority. Chlamydia-infection remains the most prevalent STD. It is easily diagnosed by DNA-diagnostic amplification techniques. The new guidelines recommend more proactive and wider testing. There is much emphasis on counselling, prevention and notifying partners. General practice is the ideal setting for this.     

Challenges in managing patients in Australia with chronic hepatitis B: the General Practitioners’ perspective

Objective: General Practitioners (GPs) are essential to reducing the impact of chronic hepatitis B (CHB) given their clinical management role where only 56% of people with the infection in Australia have been diagnosed. This qualitative study aimed to identify the challenges GPs face in effectively responding to CHB. Methods: Semi‐structured interviews were conducted with 26 GPs self‐identifying as having a ‘high caseload’ of patients and/or a particular interest in CHB. Participants were recruited from five jurisdictions and came from diverse ethnicities, clinical experience and practice profile. Interview data were analysed according to the principles of grounded theory. Results: Patient and GP knowledge, a lack of community awareness, and language and cultural diversity impeded the GP response to CHB. Communication with specialists was reported as challenging with unclear referral pathways, limited feedback from specialists after referral, and poor liaison and support for managing people living with CHB. Regulations restricting GPs capacity to respond included the lack of prescribing opportunities, fear of Medicare auditing for screening the populations most at risk, and inadequate financial support given the complexity of CHB and the communities most affected by the infection. Conclusions: General Practitioners require additional skills and resources to support the effective management of people with CHB. These include improved awareness and knowledge about the infection, adequate financial resources to support patient management, and effective referral pathways and support.     

The Promoting Effective Advance Care for Elders (PEACE) randomized pilot study: theoretical framework and study design

Practice guidelines are available for hospice and palliative medicine specialists and geriatricians. However, these guidelines do not adequately address the needs of patients who straddle the 2 specialties: homebound chronically ill patients. The purpose of this article is to describe the theoretical basis for the Promoting Effective Advance Care for Elders (PEACE) randomized pilot study. PEACE is an ongoing 2-group randomized pilot study (n=80) to test an in-home interdisciplinary care management intervention that combines palliative care approaches to symptom management, psychosocial and emotional support, and advance care planning with geriatric medicine approaches to optimizing function and addressing polypharmacy. The population comprises new enrollees into PASSPORT, Ohio's community-based, long-term care Medicaid waiver program. All PASSPORT enrollees have geriatric/palliative care crossover needs because they are nursing home eligible. The intervention is based on Wagner's Chronic Care Model and includes comprehensive interdisciplinary care management for these low-income frail elders with chronic illnesses, uses evidence-based protocols, emphasizes patient activation, and integrates with community-based long-term care and other community agencies. Our model, with its standardized, evidence-based medical and psychosocial intervention protocols, will transport easily to other sites that are interested in optimizing outcomes for community-based, chronically ill older adults.     

General practitioners' uptake of clinical practice guidelines: a qualitative study

OBJECTIVE: To explain recent rapid audited change in the uptake of locally implemented, evidence-based clinical guidelines for asthma and angina in primary care. METHODS: A case study of primary care in two matched, adjacent districts in Northern England, focusing on a stratified random sample of 49 general practitioners (GPs) from eight primary care groups. Data were collected from three cycles of mainly qualitative interviews carried out at six-monthly intervals, before and after the dissemination of local guidelines and after audit data were gathered. Interviews examined attitudes, awareness and impact of locally disseminated asthma and angina guidelines and the subsequent audit. Audit data on guideline uptake were also available from a parallel study. RESULTS: The rapid increase in guideline uptake observed in both intervention and control groups was not explained by individual practitioners or practice factors. The findings are attributed to GPs' awareness of policies for evidence-based medicine, of new health service institutions and of the clinical governance activities of primary care groups. Behaviour change reflects GPs' decisions about what to record in case notes as well as their clinical decisions, so that findings may reflect changing perceptions about accountability rather than about preferred treatment regimes. CONCLUSIONS: Guideline production and dissemination is best seen in the broader context of policy change. Studies of guideline implementation should report before and after data and incorporate significant qualitative components in order to identify important contextual factors.