Eileen J Wilson
Clinical practice guidelines (CPGs) are seen, in part, as a way to put evidence into clinical practice. However, adoption of CPGs by clinicians and their effectiveness in changing clinical practice have been far from ideal.1-4 In recent years, researchers have begun to address shortcomings in guideline dissemination and implementation.5-8 Many now believe that a multi-faceted approach is necessary for the successful implementation of CPGs. This approach requires an assessment of the barriers to change in the target population9 10 and development of appropriate implementation strategies that address these barriers to change.11-13
This case study illustrates a multi-faceted approach to the development and implementation of guidelines for acute respiratory infections (ARI) within a randomised controlled trial. A series of focus groups and workshops were held with parents of young children and GPs to explore issues of antibiotic use for ARI. Participants discussed the barriers that might prevent a more prudent use of antibiotics. We matched intervention strategies that could assist GPs and consumers in reducing unnecessary antibiotic use for ARI to these barriers. Each workshop and focus group built progressively and culminated in a final GP meeting that edited a 'Principles of Practice' document for GPs, and approved guidelines for parents and an implementation package containing educational materials, posters and clinical consultation aids.
Using the above method, we identified many barriers that could impede the successful implementation of evidence-based guidelines into clinical practice.
Time: GPs frequently cited time as a reason for prescribing antibiotics. Consultations for otitis media, for example, were often seen as a chance to 'catch up' on the backlog of patients in the waiting room. The ear could be examined and a prescription written in a short period. The parents expected antibiotics for this condition and accepted a quick consultation. Other GPs felt that during the winter months they spent too much time explaining repeatedly to each new patient with an upper respiratory tract infection about viral aetiology and the ineffectiveness of antibiotic treatment for this condition. We addressed aspects of this time barrier by providing practitioners with patient information sheets and "ARI Prescription Pads". The information sheets provided the GPs and consumers with an efficient educational tool. The prescription-like pads allowed the GP to tick a series of boxes to explain the diagnosis, recommend symptomatic treatment, and caution on warning signs if improvement was not seen. Thus to overcome the time barriers we employed marketing, educational, and organisational approaches in devising implementation strategies.
Lack of knowledge: The workshops discussed the available evidence for the treatment of ARI and explored variations in practice. GPs who felt their practice was already good enough or who lacked the knowledge of the evidence could explore those issues among their peers in a non-threatening environment. The workshop used an epidemiological, educational, and social interaction approach to guideline development to educate the GPs and change their perceptions of their practice.
Doubt about evidence: Some of the GPs felt that the evidence in the literature, based on randomised controlled trials, presented an artificial situation. Others were skeptical about the criteria used for case inclusion in studies. They felt the conclusions from the research trials were not necessarily relevant to every day practice. Experts in evidence-based medicine, infectious disease, and paediatrics were present at some of the workshops to help explain the details of published studies and strengthen the validity of the evidence for these GPs.
Fear of patient dissatisfaction: GPs expressed a fear of patient dissatisfaction that could result in the loss of patients to other doctors who may prescribe antibiotics more freely. To counter this barrier, we presented GPs with information from the parent focus groups that revealed parents generally wanted to reduce antibiotic use. They primarily went to the GP wanting reassurance and advice in management rather than an antibiotic prescription. Parents in the study were also given a consumer version of the guidelines that helped to educate the consumers and improve understanding of any change in their GP's practice.
Fear of poor health outcomes: GPs were concerned about possible poor health outcomes if their approach towards ARI treatment became less interventionist. We used a marketing step-wise approach to address this barrier. We encouraged GPs to use antibiotics less often in the mild cases first. This would enable GPs to gain confidence in the new style of practice and provide empirical evidence that it did not produce poor health outcomes. We were also able to reassure the GPs that the results of their changed practice would be evaluated as part of the randomised controlled trial and they would be given an assessment of the results.
Fear of litigation: Concern about litigation was an extension of the economic concern of losing patients and income and a concern for loss of prestige among their colleagues. We approached this economic and social barrier by obtaining the endorsement and support of experts. This support gave the GPs further reassurance to change their clinical behaviour.
Reluctance to change: Underlying the above barriers was a general non-specific fear of change, of practicing medicine differently. GPs saw prescribing antibiotics for ARI as a safety net; an assurance that they were treating a condition rather than being perceived as doing nothing. Others saw no need to change as they felt their practice was already evidence based. Encouraging the GPs to try the new style of practice on the less severe cases first would give them confidence to change and evidence that their practice could be improved.
This case study illustrates the need for evidence based health care to incorporate more than an understanding of the best clinical evidence. If clinicians and consumers are to incorporate evidence into their clinical decision making, the psychological, social, economic, and organisational aspects related to those decisions must also be addressed. For evidence based health care to be implemented through clinical practice guidelines, all the aspects of decision making and behaviour change need to be consolidated in the same systematic way as is done with clinical evidence. A multi-skilled, inter-disciplinary approach seems to be warranted.
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