2 Editorial

Editorial

Do general practitioners need guidelines? U

Practice guidelines are “systematically developed statements to assist practitioner and patient deci- sions about appropriate health care for specific clinical circumstances” (1). Guidelines should be developed in a systematic manner by relevant experts, be aimed at clearly defined clinical sur- roundings, and their scientific basis should be stated. They should give detailed information of the appropriateness or inappropriateness of differ- ent procedures, and if there is no consensus of informed opinion, this should be stated clearly.

Guidelines development is nothing new. When the increase of information in medicine was less rapid than today, medical textbooks were used as guidelines. Later, specialist societies have pro- duced guidelines in their own areas of expertise. In the United States alone, some 1200 guidelines produced by 45 different bodies are currently available (2). Our own data from Finland suggest that the situation is very similar: over 700 guide- lines have been published after 1989 by local, regional, and national bodies. The quality, length, and scientific basis of these guidelines varied greatly; only two were based on a meta-analysis of relevant literature (3).

The reasons for a rapid increase in guidelines in Europe, USA, and Canada are both scientific and practical. Improvements in methodology have revolutionized the processes for guidelines devel- opment. On the other hand, the increasing needs for cost containment have made third party payers aware of the possibilities to cut down expenses by using guidelines. The modem aim of guidelines development and implementation is to achieve actual change in physician behaviour, and through this to improve the health of the population (43).

Better methods The methodology of guidelines development and implementation has been scrutinized, and modem

infomation technology has enabled a much more rigorous process for guidelines development. The most important example of this is the Cochrane Collaboration (6). The Collaboration produces structured literature reviews using a systematic, rigorous procedure that enables the quantitative combination of data from different primary stud- ies. Such reviews are sometimes guidelines for single decisions as such, but more importantly they can be used in the process of guidelines development. In the new Finnish guidelines for screening in maternity care (7), we controlled the scientific basis of each recommendation against the Cochrane Database on Pregnancy and Child- birth (8). The user of this guideline can see for himselfherself that some procedures have sound trial-level basis, while others lack such basis and accordingly expert opinions in the subject may differ.

In general practice, using guidelines is not a simple and straightforward issue. Guidelines are often targeted for use in secondary care popula- tions or they assume a level of expertise or equip- ment not generally available in primary care cir- cumstances. Guidelines are published in multiple fora, and it is often difficult to find time to look up a certain guideline during a busy practice session.

Systematic development of guide- lines A comprehensive approach for primary care guidelines development has been taken in The Netherlands and Finland. Dutch general practi- tioners have developed a set of over 40 guide- lines, using a systematic procedure, specifically for general practice (9). The Society of General Practitioners has paid special attention to the practicability of these guidelines by asking for comments about the drafts from 50 randomly

Scand J Prim Health Care 1996; 14

Scan

d J

Prim

Hea

lth C

are

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

98.2

24.3

9.20

on

11/0

3/14

For

pers

onal

use

onl

y.

Editorial 3

chosen general practitioners. The Society has also promoted the use of these guidelines with a train- ing programme, and is in the process of evaluat- ing the effects of its guidelines.

The Finnish Medical Society Duodecim has funded the production of Physicians Desk Refer- ence and Database (10). This is a set of guidelines edited specifically for primary care and available in both printed and electronic format. The elec- tronic guidelines can be used with any patient record program on a personal computer or a com- puter network. The physicians with the computer version in their practices consult it three times daily on the average. In half of these consulta- tions, the guideline influenced the physician’s clinical decision (Jousimaa J, personal communi- cat ion).

The guidelines should also be useful and under- standable for the patient. General practitioners are used to explaining the pros and cons of different investigations and treatments to their patients. A new approach, used already in the United States, is the creation of patient’s guidelines alongside those meant for professionals. Patient representa- tives may even participate in formulating guide- lines understandable for lay persons. These are most welcome ways of ensuring both trust in pro- fessionals and compliance with mutual decisions.

Guidelines are necessary General practitioners do indeed need guidelines in their work. These guidelines must be written for their own patient populations and working envi- ronments. The quality of information behind the guidelines must be stated clearly, and the guide- lines need to be updated regularly. Most impor- tantly, the guidelines must be easy to use during a busy practice session. In order to develop good guidelines, the general practitioners themselves must combine their efforts both with their fellow general practitioners internationally and with other specialists in their own countries.

References 1. Institute of Medicine. Guidelines for clinical prac-

tice: from development to use. Washington, DC: National Academic Press, 1992.

2. Oxman A, Coordination of guidelines develop- ment. Can Med Assoc J 1993;148:1285-8.

3. Varonen H, M&ela M. Suomalaiset hoitosuosituk- set. (Finnish guidelines. In Finnish.) Duodecim 1996;112, in print.

4. Grimshaw J, Russell I. Achieving health gain through clinical guidelines. I: Developing scientifi- cally valid guidelines. Qual Health Care

5. Grimshaw J, Russell I. Achieving health gain through clinical guidelines. 11: Ensuring guidelines change medical practice. Qual Health Care

6. Chalmers I, Dickersin K, Chalmers TC. Getting to grips with Archie Cochrane’s agenda. BMJ

7. Seulontatutkimukset ja yhteistyo aitiyshuollossa. (Screening and collaboration in maternity care. In Finnish.) Stakes, Oppaita 27. Gummerus Kir- japaino Oy, Jyvaskyla, 1995.

8. Cochrane Database of Systematic Reviews. Preg- nancy and Childbirth Module (CCPC). Oxford: Up- date Software, 1994, Disk Issue 2.

9. Dutch College of General Practitioners. NHG Stan- dards. Five examples of guidelines for general practice. Utrecht: Nederlands Huisartsen Genoot- schap, 1993.

10. Jousimaa J, Kunnamo I: PDRD - a computer-based primary care decision support system. Med Inf

1993;2:243-8.

1994;3:45-52.

1992;305:786-7.

1993; 18: 103- 12.

Marjukka Mtikela Stakes (National research and development centre for welfare and health) Services and Quality P.O.Box 220 FIN-0053 1 Helsinki Finland

Scund J Prim Health Cure 1996; 14

Scan

d J

Prim

Hea

lth C

are

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

98.2

24.3

9.20

on

11/0

3/14

For

pers

onal

use

onl

y.