Baker, R

Chan, AKL

Chan, LWY

Hong, TTC

Kwong, MBL

Lam, TP

Hong Kong Medical Journal

HKU Scholars Hub

Title Strengthening primary care: The role of clinical practiceguidelinesAuthor(s) Chan, AKL; Baker, R; Lam, TP; Kwong, MBL; Chan, LWY; Hong,TTCCitation Hong Kong Medical Journal, 2010, v. 16 n. 1, p. 73-74Issued Date 2010URL http://hdl.handle.net/10722/65447Rights Creative Commons: Attribution 3.0 Hong Kong License	 Hong	Kong	Med	J		Vol	16	No	1	#	February	2010	#		www.hkmj.org	 73IntroductionClinical practice guidelines (CPGs) have been developed, disseminated, and implemented to assist health providers and patients to make clinical decisions, reduce unwarranted variations, and assure and improve the quality of care. The role CPGs may play as a means of strengthening primary care in Hong Kong has yet to be explored. The Hong Kong College of Family Physicians began to draft guidelines on conditions like diabetes mellitus,1 asthma,2 and vaginal discharge3 in 1991. The Department of Health’s Professional Development and Quality Assurance website currently displays CPGs on pertinent primary care conditions like type 2 diabetes mellitus, hypertension, and lipid management.4 In his 2009/2010 policy address, the Hong Kong Chief Executive pledged to provide additional resources for developing chronic disease management protocols.5 At this crossroad, where CPG development may play a role in shaping Hong Kong’s primary care, what is the evidence that the use of CPGs improves patient health outcomes? What factors may facilitate primary care doctors’ adherence to the guideline recommendations? This issue—whether or not CPGs improve health outcomes in primary care—was debated during a recent symposium: ‘Primary care for Hong Kong…the way forward’. A newly published systematic review of the impact of CPGs in The Netherlands reported improvement in the process and structure of care, with small but significant improvements in health outcomes (for example, glycosylated haemoglobin was lowered by 1.7%).6 Hence, there is some evidence that planned and thoughtful implementation of high-quality CPGs does improve the structure, process, and outcomes of primary care in specific populations.The implementation of guidelines among primary care doctorsSurveys in The Netherlands, United States, United Kingdom, Italy, Canada, Australia, Denmark, Ireland, and Israel have found that most doctors are supportive of CPGs, finding them to be useful, educational, and likely to improve the quality of care.7 This positive attitude, however, does not automatically translate into practice changes. Nearly half of the respondents were concerned about the increased likelihood of litigation or disciplinary action.Strengthening primary care: the role of clinical practice guidelines Non-adhering doctors are those who are not aware of, or not familiar with, CPGs; who do not have the self-confidence to apply the recommendations; who do not expect to achieve good outcomes by following guidelines; who want to stick to their previous practices; and who are constrained by external barriers, such as patient preferences or a lack of resources.8 Qualitative studies in the United Kingdom, United States, Canada and The Netherlands have highlighted the value general practitioners (GPs) place on seeing every patient as a unique individual.9 Many GPs argued that population-based trials were not equally applicable to all and that use of a ‘one-size-fits-all’ prescription may pose difficulties in practices with differing demographics. Nearly all CPGs focus on single diseases, but many patients have multiple co-morbidities. Hence, flexibility or contextualisation should be built into the recommendations and CPGs should not be turned into performance measures used to critique the quality of primary care. As yet no single method of implementing CPGs has been shown to be reliably effective in all settings and circumstances.10 In a study of Dutch GPs, within each guideline, individual recommendations encountered a unique pattern of barriers.11 A UK ethnographic study showed that GPs seldom used formal sources of evidence that were codified in a direct, linear, or rational manner.12 “Mindlines” (instead of “guidelines”) were formed by brief reading (like leafing through a new guideline that had arrived in the mail), as much as by interactions with each other and by other knowledge that built on early training and experience. Hence implementation strategies should capitalise on the community context and on GP networks. Conroy and Shannon13 wrote that “Success in changing clinical practice may depend less on scientific method and more on imagination, flexibility, enthusiasm and application of principles derived from marketing and social influence theories.” Formats of CPG strongly influence the attitudes towards them, hence more thought should be put into making CPGs user-friendly and attractive. Grol14 pointed out that it is important to “know your target group” and “see their situation through their eyes”. Several studies have shown that involving primary care doctors in the process of developing CPGs will enhance their use in daily practice.15,16 The use of economic incentives for guideline implementation is controversial. It C o m m e n T a r y		#		Chan	et	al	#74	 Hong	Kong	Med	J		Vol	16	No	1	#	February	2010	#		www.hkmj.orgreferences1.	 Research	Committee.	Management	guidelines.	Diabetes	mellitus.	Hong	Kong	Pract	1992;14:2346-51.2.	 Research	Committee.	Management	guidelines.	Bronchial	asthma.	Hong	Kong	Pract	1993;15:2885-9.3.	 Research	Committee.	Management	guidelines.	Vaginal	discharge.	Hong	Kong	Pract	1994;16:457-61.4.	 Professional	 development	 and	 quality	 assurance.	HKSAR	Department	 of	Health	website:	 http://www.pdqa.gov.hk/english/primarycare/clinical/cmp.php.	Accessed	12	Nov	2009.5.	 Breaking	new	ground	together.	2009-10	Policy	Address.	HKSAR	Government	website:	http://www.policyaddress.gov.hk/09-10/index.html.	Accessed	30	Oct	2009.6.	 Lugtenburg	M,	Burgers	JS,	Westert	GP.	Effects	of	evidence-based	clinical	practice	guidelines	on	quality	of	care:	a	systematic	review.	Qual	Saf	Health	Care	2009;18:385-92.7.	 Farquhar	 CM,	 Kofa	 EW,	 Slutsky	 JR.	 Clinicians’	 attitudes	 to	 clinical	 practice	 guidelines:	 a	 systematic	 review.	Med	 J	 Aust	2002;177:502-6.8.	 Cabana	MD,	Rand	CS,	Powe	NR,	et	al.	Why	don’t	physicians	follow	clinical	practice	guidelines?	A	framework	for	improvement.	JAMA	1999;282:1458-65.9.	 Carlsen	B,	Glenton	C,	Pope	C.	Thou	shalt	versus	thou	shalt	not:	a	meta-synthesis	of	GPs’	attitudes	to	clinical	practice	guidelines.	Br	J	Gen	Pract	2007;57:971-8.10.	Grimshaw	JM,	Thomas	RE,	MacLennan	G,	et	al.	Effectiveness	and	efficiency	of	guideline	dissemination	and	implementation	strategies.	Health	Technol	Assess	2004;8:iii-iv,1-72.11.	Lugtenberg	M,	Zegers-van	Schaick	JM,	Westert	GP,	Burgers	JS.	Why	don’t	physicians	adhere	to	guideline	recommendations	in	practice?	An	analysis	of	barriers	among	Dutch	general	practitioners.	Implement	Sci	2009;4:54.	12.	Gabbay	J,	 le	May	A.	Evidence	based	guidelines	or	collectively	constructed	“mindlines”?	Ethnographic	study	of	knowledge	management	in	primary	care.	BMJ	2004;329:1013-6.	13.	Conroy	M,	Shannon	W.	Clinical	guidelines:	their	implementation	in	general	practice.	Br	J	Gen	Pract	1995;45:371-5.14.	Grol	R.	Implementing	guidelines	in	general	practice	care.	Quality	in	Health	Care	1992;1:184-91.15.	Hayward	RS,	Guyatt	GH,	Moore	KA,	McKibbon	KA,	Carter	AO.	Canadian	physicians’	attitudes	about	and	preferences	regarding	clinical	practice	guidelines.	CMAJ	1997;156:1715-23.16.	Carlsen	B,	Norheim	OF.	“What	lies	beneath	it	all?”—an	interview	study	of	GPs’	attitudes	to	the	use	of	guidelines.	BMC	Health	Serv	Res	2008;8:218.17.	Checkland	K,	Harrison	S,	McDonald	R,	Grant	S,	Campbell	S,	Guthrie	B.	Biomedicine,	holism	and	general	medical	practice:	responses	to	the	2004	General	Practitioner	contract.	Sociol	Health	Illn	2008;30:788-803.18.	Shaneyfelt	TM,	Centor	RM.	Reassessment	of	clinical	practice	guidelines:	go	gently	into	that	good	night.	JAMA	2009;301:868-9.has been shown to be favoured by British GPs17 but other countries (for example, Norway) did not consider use of financial rewards a suitable method for promoting guideline implementation.15 Whether Hong Kong should follow the British model is open for discussion. As guideline development is expensive, time- and skill-demanding, centrally developed guidelines are more likely to facilitate the concentration of resources for a comprehensive and trustworthy output. A recent JAMA editorial condemned the practice whereby pharmaceutical industry and specialty societies use guidelines to expand their share of the competitive medical marketplace.18 In Hong Kong, it is unlikely that primary care CPGs would be developed de novo, but the process of adapting international guidelines should be scrutinised to ensure the recommendations are made impartially.ConclusionIf implemented, evidence-based CPGs can potentially improve quality of care. Worldwide, primary care doctors are supportive of CPGs. If guideline end-users are involved, any central agency set up to adapt international CPGs is likely to be more efficient and credible. Further studies are needed to identify the strategies that are most significant, relevant and likely to have an impact on Hong Kong’s guideline development policy.amy KL Chan, FRACGP, FHKCFPEmail: dramychan@graduate.hku.hkPrivate practicerichard Baker, MD, FRCGPDepartment of Health Sciences, University of Leicester, United KingdomTP Lam, MD, FHKAM (Family Medicine)Family Medicine Unit, The University of Hong Kong, Hong Kongmary BL Kwong, FHKAM (Paediatrics), FHKCFPPrivate practiceLoretta Wy Chan, FHKAM (Family Medicine), FRACGPFamily Medicine Unit, The University of Hong Kong, Hong KongTimothy TC Hong, FHKCFP, FRACGPDepartment of Family Medicine and Primary Health Care, United Christian Hospital, Hong Kong

Strengthening primary care: The role of clinical practice guidelines

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Strengthening primary care: The role of clinical practice guidelines

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