Challenges of adhering to clinical practice guidelines in general practice: A quantitative study of a guideline for follow-ups after insertion of tympanic membrane ventilation tubes, and a qualitative study of GPs’ experiences with clinical practice guidelines

Abstract

Background: Clinical guidelines are important in medicine. Quality of care is increasingly based on research and EBM, and developing recommendations based on EBM is prioritized in many countries. Still, it is well known that adherence to guidelines in general practice is low, and, apparently, the reasons for this are complex. Insertion of ventilation tubes (VTs) in the tympanic membrane is one of the most common ambulatory surgeries performed on children in Norway. It is most often performed because of otitis media with effusion. Previously, all children had their follow-ups performed by otolaryngologists. The University Hospital in Mid-Norway modified their guideline for follow-ups after surgery so that the controls of the healthiest children were to be conducted by general practitioners (GPs). The guideline was controversial when it was introduced. This guideline is one of many that GPs are expected to apply. While the term ‘guideline’ has long referred to recommendations that are not necessarily based on a systematic appraisal of the evidence, the term ‘Clinical Practice Guidelines’ (CPGs) is now to be used only when such systematic appraisals are included (see 1.2.1). However, a very limited amount of research has been done regarding the challenges presented by the total number of guidelines and CPGs that are to be adhered to in general practice. Aims: The aim of this project was to study the challenges associated with implementation and adherence to clinical guidelines in general practice. More specifically: - To evaluate the process (Paper I) and patient outcome (Paper II) after implementation of a new guideline concerning follow-ups after inserting VTs in the tympanic membranes of children. - To explore GPs’ experiences with and reflections upon the use of multiple guidelines and CPGs in their daily work (Paper III), and the consequences that applying them may have for general practice (Paper IV). Material and methods: Study 1 was a retrospective, quantitative, observational study performed at Trondheim University Hospital and in my general practice, both of which are in Mid-Norway. Children under the age of 18 who had undergone an insertion of a VT between Nov. 1, 2007, and Dec. 31, 2008, (n = 136) were included. Two years after surgery, audiological tests were performed and a self-report questionnaire was assessed. Study 2 was a qualitative, focus group study carried out in Mid-Norway. The study involved 25 Norwegian GPs from four pre-existing groups. The GPs’ work histories varied from being recent graduates to having up to 35 years of experience. Interviews were audiorecorded, transcribed and analyzed using systematic text condensation, i.e. applying a phenomenological approach. Results: In Study 1, we found that, despite multifaceted methods to implement the VT-guideline at the hospital, there was a discrepancy between the guideline and the otolaryngologists’ decisions regarding scheduling of follow-up examinations. There was a greater discrepancy between the planned location for the follow-ups and where the patients’ checkups were actually performed. The implementation process was apparently inadequate for the GPs as the information was not repeated. Nevertheless, the guideline seemed to secure that postoperative controls would be conducted within general practice. Implementation of the new VT-guideline, in which GPs had responsibility for the follow-up controls of a group of the children, did not negatively affect either the audiological outcomes or the number of subjective hearing complaints two years after surgery. In Study 2 we found that GPs considered CPGs necessary. Nonetheless, they had difficulties adhering to them because, for example, the CPGs were too many, and they were inaccessible, that is, too long and too comprehensive to navigate through easily. Moreover, the GPs reported a mismatch between the CPGs and their patients. Whereas CPGs are often focused on treatment for single diseases, the GPs reported that their own focus was more on their patients as whole persons. The obligation to apply multiple CPGs designed for single diseases created various complications for the GPs, such as insecurity about their own practice and a tendency to practice medicine defensively. The complications for their patients included an increased risk of polypharmacy, of excessive non-pharmacological recommendations, of an increased tendency toward medicalization, and of a potentially reduced quality of life. Conclusion: Overall, the studies documented several challenges regarding adherence to CPGs. Even the simple VT-guideline was complex to implement in an actual clinical setting. In part, this guideline’s lack of quality may explain the lack of adherence. Further studies are needed to consider the implications for follow-up after VT surgery. The GPs provided compelling reasons for their low adherence to CPGs in general. The main reasons seemed to involve a mismatch between the CPGs and the patients, and that applying multiple CPGs for single diseases resulted in complications for general practice, especially for multimorbid patients. These findings challenge the idea that ‘quality of care’ is largely synonymous with adherence to CPGs designed specifically for single diseases in general practice. In this thesis, these findings are discussed in light of what may be called a ‘fundamental inadequacy’ in determining what is to be considered as valid medical knowledge. These issues may also help explain why CPGs are difficult to adhere to in general practice.