Towards efficient guidelines: How to monitor guideline use in primary care

Objectives: To develop a model for using routine data monitoring in the evaluation of clinical guideline usage in primary healthcare settings. Design: A monitoring framework was developed following a number of semistructured interviews with potential users. These data informed a postal survey among a random sample of primary healthcare professionals. Then to test out the framework, a further semistructured interview study was used to explore the practical issues relating to monitoring guideline use. Case studies were then undertaken to investigate the use of evidence-based review criteria and patient-centred outcome measures as methods for providing monitoring information. A case study in one general practice used interviews to examine the possible costs associated with guideline-use monitoring. Setting and participants: Interviews were undertaken with primary care professionals from one local health community. The postal survey was undertaken among staff from a purposive sample of Health Authorities in England and a random sample of general practitioners and practice nurses from the selected Health Authority areas. The second phase involved interviews with Health Authority, Primary Care Group and general practice staff from three Health Authority areas. Case studies were undertaken in volunteer general practices and among patients who consented to provide confidential health outcome information. Results: Interviewees recognised some value in guideline-use monitoring, however they were concerned about the practicalities from two perspectives. First, although primary care computing systems were to be found in most general practices, the technology for monitoring was absent in many practices. Training in these skills would be required before monitoring of guideline use could be a practical reality. Second, there were clear signals of a more general lack of interest or awareness in the subject of continuous review of care. This, together with a feeling of being overloaded with new initiatives, meant that implementation of a monitoring framework could be problematic and might need considerable support in order to make progress. Conclusions: Effective methods can be developed for monitoring guideline use in primary care. However there is a need to address the degree of understanding that many primary healthcare professionals have of the concepts and practical issues in the area of guideline-use monitoring, and of expectations of this within the NHS. In addition there are a number of technical issues concerned with efficient capture of clinical information and its evaluation. Further research is recommended in the following areas: the extent to which patient concordance with the guideline recommendations be taken into account in the assessment of clinician conformance with guideline recommendations; the costs and benefits to patient care of guideline-use monitoring; the most efficient methods of developing valid and reliable review criteria which are policy and evidence (guidelines) based; whether review criteria are more useful than guidelines in improving quality of care; what additional benefits to patient care can offered by monitoring patient-centred health outcomes in addition to process of care, and at what cost?