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The Implementation and Uptake of Clinical Guidelines in Obstetrics and Gynaecology

The College began producing clinical guidance in the form of Green-top Guidelines in 1994, and in 1996 began to produce a series of national evidence-based guidelines with funding from the Department of Health.

As a first step in assessing the uptake of clinical guidelines, the RCOG surveyed all consultant obstetricians and gynaecologists in the British Isles to assess their response to the distribution of College guidelines.

The Royal College of Obstetricians and Gynaecologists has, for a number of years, provided guidance on clinical matters. This guidance has evolved into a format now recognised as clinical guidelines. Internal RCOG guidelines, colloquially called ‘Green-top guidelines’, were first produced in 1994 and have evolved from an opinion-based to an evidence-based approach. In 1996, funded by the Department of Health, the College then embarked on a series of national evidence-based guidelines. These guidelines embraced whole areas of clinical practice and adopted a systematic approach, using multidisciplinary groups and explicit literature-search strategies, a methodology now recognised as appropriate to clinical guideline development.1,2

The distribution of methodologically sound clinical guidance does not, however, ensure implementation.3-5 This particular issue has been addressed in a number of ways, reviewed in 1999 by the NHS Centre for Reviews and Dissemination.3 A key recommendation in this respect is that any systematic approach to clinical effectiveness should include plans to evaluate change.

As a first step in assessing the uptake of clinical guidelines, the College undertook a survey of all consultant obstetricians and gynaecologists in the British Isles to assess their response to the distribution of College guidelines. This paper reports the outcome of that survey.

Methods

The survey was carried out in May-July 1999. At that time, three national evidence-based guidelines had been distributed: namely, The Initial Management of Menorrhagia,7-9 The Initial Investigation and Management of the Infertile Couple 5 and The Management of Infertility in Secondary Care.6

In addition, the College has, since 1994, distributed internal (Greentop) guidelines, now numbering 28 and covering disparate areas of clinical practice, including, for example, amniocentesis, chickenpox in pregnancy and the management of tubal pregnancies.

About two-thirds of the questions in the survey related to the RCOG clinical effectiveness programme and in particular the guidelines, both national and internal. About one-quarter of questions were concerned with the specific recommendations of one particular guideline, The Initial Management of Menorrhagia. The remaining questions related to a number of characteristics used as control variables in the analysis. These included year of obtaining MRCOG, size of clinical unit (as judged by number of deliveries and number of consultants working in the department) and subspecialty interest.

The questionnaire was mailed to all 1447 consultants in the UK, Northern Ireland and Republic of Ireland, registered on the College database. This was accompanied by a letter describing the objectives of the survey and a reply-paid envelope. Only one mailing was used.

A total of 874 (60.4%) questionnaires was returned. Of these, 26 (2.9%) were returned blank by respondents whose clinical practice excluded those areas covered by the guidelines. The data described in this paper are based on the remaining 848 questionnaires, a usable response rate of 58.6%.

The answers to open questions were categorised and coded. Data were analysed using SPSS for Windows (release 9.0.0). Associations were tested for significance using × 2.

Results

Individual response

Most respondents were aware of the three national evidence-based guidelines, ranging from 89.2% to 98.2%, with the highest rate of awareness being for the first guideline distributed (on menorrhagia). A high proportion of consultants (94.2%) had the guidelines available for reference, while the remainder were unsure where they were or had thrown them away.

In relation to impact on individual clinical practice, 49.9% felt that the three guidelines had provoked change, 38.1% felt there had been no impact and 10.8% were not sure. However, the most common reason offered by 340 respondents who felt no impact or were unsure was ‘already practicing or not applicable’ (90.3%). Thus, less than 10% of these respondents and less than 4% overall had specific objections to one or more of the guidelines or were negative in some other way.

Table 1. Responses to questions about format of national evidence-based and internal RCOG guidelines, based on 848 returned questionnaires

 

Question National evidence-based guidelines responses: n (%)
  Right Wrong Unsure Missing
Content 563 (66) 33 (4) 202 (24) 50 (6)
Layout 551 (65) 32 (4) 215 (25) 50 (6)
Frequency 405 (48) 72 (9) 307 (36) 64 (7)
Subject choice 454 (54) 61 (7) 275 (32) 58 (7)
Development method 408 (48) 63 (7) 278 (33) 99 (12)
 
Question Internal RCOG guidelines responses: n (%)
  Right Wrong Unsure Missing
Content 535 (63) 42 (5) 207 (24) 64 (8)
Layout 516 (61) 50 (6) 214 (25) 68 (8)
Frequency 468 (55) 68 (8) 245 (29) 67 (8)
Subject choice 514 (61) 46 (5) 221 (26) 67 (8)
Development method 413 (49) 62 (7) 262 (31) 111 (13)


Departmental response

Only 39.3% of 819 respondents indicated that there was a departmental strategy for dealing with guidelines. Among the remaining 497 where there was no strategy, reasons included ‘had nonetheless been discussed at meetings’ (22.7%), ‘presently under consideration’ (29.1%), ‘up to individual consultants’ (11.9%) and ‘no need’ (6.4%). Consultants were also asked if they were aware of any specific departmental response to the guidelines (examples given included development of protocols and audit of current practice) and 64.5% indicated positively. In this case, smaller departments were significantly more likely to have responded positively (P = 0.006).

Guideline methodology

Only a minority of consultants (48.8%) saw any difference between national (evidence-based) and internal (RCOG) guidelines, although an equal number were unsure or did not know. Subspecialists, as opposed to generalists, were significantly more likely to perceive a difference (P = 0.03).

Presentational aspects were generally well received, as was frequency, subject choice and development process. This applied to both national and internal guidelines. The detail is summarised in Table 1.

Reported clinical practice

The questionnaire also focused on several recommendations taken from one particular guideline, The Initial Management of Menorrhagia. Of the 798 respondents who answered this section, 83.0% felt the guideline was helpful, 9.5% had not and 7.5% were unsure. However, only 14.6% agreed with all 13 recommendations in the guideline, although 78.8% agreed with the majority. Only 1.2% agreed with a minority or none at all. In terms of clinical practice, 21.8% routinely and 63.3% selectively performed endometrial biopsy (in the initial assessment of menorrhagia) while only 14.9% did not (the guideline recommends that endometrial biopsy is not performed). Similarly, 39.8% routinely or selectively prescribed luteal phase norethisterone for the treatment of menorrhagia, a treatment that the guideline indicates is ineffective.

There was no association between adherence to these two recommendations and the seniority of the consultant (as judged by year of obtaining MRCOG) or the size of the unit (as judged by the number of consultants and number of deliveries).

Discussion

As far as we are aware, this is the first time all consultants from one specialty have been surveyed in relation to guideline uptake. Although the overall response, at 59%, could perhaps have been greater, the indications are that the responses were representative. The survey has indicated a high level of awareness of the College’s clinical guidelines programme, with the majority of consultants in the British Isles responding positively to distribution, content, subject matter and methodology. However, a minority of clinical departments have a specific strategy in place to deal with guidelines although, perhaps more reassuringly, two-thirds of consultants indicated that there had been some form of departmental response to their distribution. A key issue in implementation is the development of local protocols based on national recommendations and evidence.7

The individual responses to the distribution of the guideline on menorrhagia are revealing. Although nearly all consultants approved all or most of the individual recommendations, this was not reflected in their clinical practice, with 85% still performing in all or selected cases an unnecessary investigation (endometrial biopsy) and 40% prescribing an ineffective treatment (luteal phase norethisterone). Furthermore, there are likely to be differences between reported and actual practice, as seen in other national surveys.10 Clearly, this requires further assessment and this particular clinical situation may require audit in due course. The development of audit criteria based on clinical guidelines is recognised as a key step in any clinical effectiveness programme.

A positive response to the distribution of the guidelines was not characterised by any of the variables we studied in this survey, including seniority of consultant and size of clinical unit, although subspecialists appear to be more aware of differences in guideline methodology than generalists. Both positive and negative responses to all questions were evenly distributed throughout all age groups and unit sizes, suggesting that these are individually rather than environmentally determined. Furthermore, it is evident that any organisational circumstances that promote or inhibit change are not characterised by old or young consultants or large or small departments.

Further research is needed to identify the characteristics of those individuals and departments who have instituted change or at least responded positively to clinical guidance, and to discover some of the individual and institutional barriers to change and development. Much has been written and reviewed in this area and, considering the enormous investment in clinical effectiveness, the research base on means of putting recommendations into practice remains inadequate.11 Without effective methods of translating evidence and research into practice, benefits for patients will not be realised and resources spent on research and the production of clinical guidelines will not be optimised.

Often, the views and actions of opinion leaders are likely to be of more practical importance than other intervention strategies, including meetings and educational material, which have produced mixed results.11 Change can most effectively be brought about by an individual or group taking responsibility for development of part of the clinical service. Eventually, it is this responsibility that may separate consultants from specialists in future years. In the meantime, the RCOG will continue through its clinical effectiveness programme to work to understand more of dissemination and implementation strategies and through these raise clinical standards to improve women’s health.

Acknowledgements

This work was undertaken by the Royal College of Obstetricians and Gynaecologists, who received funding from the Department of Health. The views expressed in this publication are those of the authors and not necessarily those of the Department of Health.

Author details

Survey and Writing Committee

  • Allan Templeton FRCOG, Chairman, Guidelines and Audit Committee, RCOG 27 Sussex Place, Regent's Park, London NW1 4RG, UK (corresponding author)
  • Mark Charny MB BChir, Director, former National Centre for Clinical Audit, Department of Health
  • Jane Thomas MRCOG, Director, Clinical Effectiveness Support Unit, RCOG
  • Charnjit Dhillon, Clinical Governance and Standards Manager, RCOG
  • References

  1. Mann T. Clinical Guidelines: Using Clinical Guidelines to Improve Patient Care Within the NHS. Leeds: NHS Executive; 1996
  2. Scottish Intercollegiate Guidelines Network. SIGN Guidelines: An Introduction to SIGN Methodology for the Development of Evidence-based Clinical Guidelines. Edinburgh; 1999. Publication No. 39
  3. Coltart T, Edmonds DK, al-Mufti R. External cephalic version at term: a survey of consultant obstetric practice in the United Kingdom. Br J Obstet Gynaecol 1997;104:544-7
  4. Leviton LC, Goldenberg RL, Baker CS, Schwartz RM, Freda MC, Fish LJ, et al. Methods to encourage the use of antenatal corticosteroid therapy for fetal maturation: a randomized controlled trial. JAMA 1999;281:46-52
  5. Foy R, Nelson F, Penney G. Awareness among obstetric and midwifery staff in Scotland of key recommendations from the Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1994-1996. J Clin Excellence 2000;2:29-33
  6. NHS Centre for Reviews and Dissemination. Getting evidence into practice. Effective Health Care 1999;5(1)
  7. Royal College of Obstetricians and Gynaecologists. The Initial Management of Menorrhagia. London; October 1998. Evidence-based Guideline No. 1
  8. Royal College of Obstetricians and Gynaecologists. The Initial Investigation and Management of the Infertile Couple. London; February 1998. Evidence-based Guideline No. 2
  9. Royal College of Obstetricians and Gynaecologists. The Management of Infertility in Secondary Care. London; February 1998. Evidence-based Guideline No. 3
  10. Penney G, Vale L, Souter V, Templeton A. Endometrial assessment procedures: an audit of current practice in Scotland. Hum Reprod 1997;12:2041-5
  11. Freemantle N, Harvey EL, Wolf F, Grimshaw JM, Grilli R, Bero LA. Printed educational materials: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2000;(1)

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