Perceptions and attitudes of clinicians in Spain toward clinical practice guidelines and grading systems: a protocol for a qualitative study and a national survey

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Abstract

Background

Clinical practice guidelines (CPGs) have become a very popular tool for decision making in healthcare. While there is some evidence that CPGs improve outcomes, there are numerous factors that influence their acceptability and use by healthcare providers. While evidence of clinicians' knowledge, perceptions and attitudes toward CPGs is extensive, results are still disperse and not conclusive. Our study will evaluate these issues in a large and representative sample of clinicians in Spain.

Methods/Design

A mixed-method design combining qualitative and quantitative research techniques will evaluate general practitioners (GPs) and hospital-based specialists in Spain with the objective of exploring attitudes and perceptions about CPGs and evidence grading systems. The project will consist of two phases: during the first phase, group discussions will be carried out to gain insight into perceptions and attitudes of the participants, and during the second phase, this information will be completed by means of a survey, reaching a greater number of clinicians. We will explore these issues in GPs and hospital-based practitioners, with or without previous experience in guideline development.

Discussion

Our study will identify and gain insight into the perceived problems and barriers of Spanish practitioners in relation to guideline knowledge and use. The study will also explore beliefs and attitudes of clinicians towards CPGs and evidence grading systems used to rate the quality of the evidence and the strength of recommendations. Our results will provide guidance to healthcare researchers and healthcare decision makers to improve the use of guidelines in Spain and elsewhere.

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Most cited references 29

Record: found
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Effectiveness and efficiency of guideline dissemination and implementation strategies.

Geraint E R Thomas, Gavin C. Donaldson, G MacLennan … (2004)

To undertake a systematic review of the effectiveness and costs of different guideline development, dissemination and implementation strategies. To estimate the resource implications of these strategies. To develop a framework for deciding when it is efficient to develop and introduce clinical guidelines. MEDLINE, Healthstar, Cochrane Controlled Trial Register, EMBASE, SIGLE and the specialised register of the Cochrane Effective Practice and Organisation of Care (EPOC) group. Single estimates of dichotomous process variables were derived for each study comparison based upon the primary end-point or the median measure across several reported end-points. Separate analyses were undertaken for comparisons of different types of intervention. The study also explored whether the effects of multifaceted interventions increased with the number of intervention components. Studies reporting economic data were also critically appraised. A survey to estimate the feasibility and likely resource requirements of guideline dissemination and implementation strategies in UK settings was carried out with key informants from primary and secondary care. In total, 235 studies reporting 309 comparisons met the inclusion criteria; of these 73% of comparisons evaluated multifaceted interventions, although the maximum number of replications of a specific multifaceted intervention was 11 comparisons. Overall, the majority of comparisons reporting dichotomous process data observed improvements in care; however, there was considerable variation in the observed effects both within and across interventions. Commonly evaluated single interventions were reminders, dissemination of educational materials, and audit and feedback. There were 23 comparisons of multifaceted interventions involving educational outreach. The majority of interventions observed modest to moderate improvements in care. No relationship was found between the number of component interventions and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data. The majority of studies only reported costs of treatment; only 25 studies reported data on the costs of guideline development or guideline dissemination and implementation. The majority of studies used process measures for their primary end-point, despite the fact that only three guidelines were explicitly evidence based (and may not have been efficient). Respondents to the key informant survey rarely identified existing budgets to support guideline dissemination and implementation strategies. In general, the respondents thought that only dissemination of educational materials and short (lunchtime) educational meetings were generally feasible within current resources. There is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgement about how best to use the limited resources they have for clinical governance and related activities to maximise population benefits. They need to consider the potential clinical areas for clinical effectiveness activities, the likely benefits and costs required to introduce guidelines and the likely benefits and costs as a result of any changes in provider behaviour. Further research is required to: develop and validate a coherent theoretical framework of health professional and organisational behaviour and behaviour change to inform better the choice of interventions in research and service settings, and to estimate the efficiency of dissemination and implementation strategies in the presence of different barriers and effect modifiers.

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Letters, numbers, symbols and words: how to communicate grades of evidence and recommendations.

Andrew D Oxman, A Schünemann, … (2003)

The GRADE Working Group is developing and evaluating a common, sensible approach to grading quality of evidence and strength of recommendations in health care. In this article, we discuss the advantages and disadvantages of using letters, numbers, symbols or words to represent grades of evidence and recommendations. Using multiple strategies, we searched for comparative studies of alternative ways of representing ordered categories in any context. In addition, we contacted experts and reviewed theoretical work and qualitative research on how best to communicate grades of any kind quickly and clearly. We were unable to identify health care research that addressed, either directly or indirectly, the best way to present grades of evidence and recommendations. We found examples of symbols used by government, commercial and consumer organizations to communicate quality of evidence or strength of recommendations, but no comparative studies. Although a number of grading systems are used in health care and other fields, there is little or no evidence of how well various presentations are understood. Before promoting the use of specific symbols, numbers, letters or words, the extent to which the intended message is comprehended should be evaluated.

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Clinicians' attitudes to clinical practice guidelines: a systematic review.

Emma Kofa, R Slutsky, Cynthia M Farquhar (2002)

To systematically review surveys of clinicians' attitudes to clinical practice guidelines. MEDLINE, HealthStar, Embase and CINAHL were searched electronically for English-only surveys published from 1990 to 2000. We included surveys with responses to one or more of seven propositions (see below). Studies were excluded if they had fewer than 100 respondents or if the response rate was less than 60%. Thirty studies included responses to one or more of the seven items, giving a total of 11 611 responses. The response rate for the included studies was 72% (95% confidence interval [CI], 69%-75%). Clinicians agreed that guidelines were helpful sources of advice (weighted mean, 75%; 66%-83%), good educational tools (71%; 63%-79%) and intended to improve quality (70%; 60%-80%). However, clinicians also considered guidelines impractical and too rigid to apply to individual patients (30%; 23%-36%), that they reduced physician autonomy and oversimplified medicine (34%; 22%-47%), would increase litigation (41%; 32%-49%) and were intended to cut healthcare costs (52.8%; 39%-66%). Surveys of healthcare providers consistently report high satisfaction with clinical practice guidelines and a belief that they will improve quality, but there are concerns about the practicality of guidelines, their role in cost-cutting and their potential for increasing litigation.

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Author and article information

Journal

Journal ID (nlm-ta): BMC Health Serv Res

Title: BMC Health Services Research

Publisher: BioMed Central

ISSN (Electronic): 1472-6963

Publication date Collection: 2010

Publication date (Electronic): 3 December 2010

Volume: 10

Page: 328

Affiliations

[1 ]Catalan Agency for Health Technology Assessment and Research (CAHTA), Roc Boronat 81-95, Barcelona, Spain

[2 ]Iberoamerican Cochrane Centre, Clinical Epidemiology and Public Health Department, Institute of Biomedical Research (IIB Sant Pau). Barcelona, Spain

[3 ]Instituto Aragonés de Ciencias de la Salud, Zaragoza, Spain

[4 ]Agencia Laín Entralgo. Consejería de Sanidad y Consumo de la Comunidad de Madrid, Spain

[5 ]Instituto de Biomedicina de Sevilla. Virgen del Rocío University Hospital, Sevilla, Spain

[6 ]CIBER de Epidemiología y Salud Pública (CIBERESP), Spain

[7 ]Servicio de Docencia y Desarrollo Sanitarios. Departamento de Salud Gobierno de Navarra, Spain

[8 ]Unidad Docente de Medicina Familiar y Comunitaria de Sevilla. Sevilla, Spain

[9 ]Avedis Donabedian Institute, Universidad Autónoma de Barcelona, Barcelona, Spain

[10 ]Centro de Salud de Alza, Donostia-San Sebastián, Spain

[11 ]Consultas Médicas y Psicológicas, Barcelona, Spain

Article

Publisher ID: 1472-6963-10-328

DOI: 10.1186/1472-6963-10-328

PMC ID: 3016354

PubMed ID: 21129195

SO-VID: 91a8f5e5-1c2c-4857-ba61-69c2c620a5df

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (<url>http://creativecommons.org/licenses/by/2.0</url>), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 11 June 2010

Date accepted : 3 December 2010

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Most cited references 29

Effectiveness and efficiency of guideline dissemination and implementation strategies.

Letters, numbers, symbols and words: how to communicate grades of evidence and recommendations.

Clinicians' attitudes to clinical practice guidelines: a systematic review.

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