Guidelines for GPs based on 'opinion rather than evidence'

Many GP guidelines are based on 'opinion rather than evidence' and could drive up practice workload and cause unnecessary stress for patients, an expert review has found.

Guidelines for testing in primary care questioned (Photo: Andrew Brookes/Getty Images)
Guidelines for testing in primary care questioned (Photo: Andrew Brookes/Getty Images)

Patients with long-term conditions could face unnecessary tests as a result of common guidelines that do not offer clear, evidence-based recommendations on best practice for GPs, according to the review carried out by the National Institute for Health Research (NIHR).

The review, published today in the British Medical Journal (BMJ), examined guidelines for chronic kidney disease, high blood pressure and type 2 diabetes.

It found that guidelines evaluated - from the National Institute for Health and Care Excellence (NICE), the Scottish Intercollegiate Guidelines Network (SIGN), the Royal Colleges of Pathologists, Physicians and General Practitioners - often were based on 'expert opinion rather than evidence'.

Evidence-based tests

Many ‘didn’t include recommendations on the frequency of testing’ required, and evidence failed to address 'the fundamental question' of whether tests being used were 'necessary or beneficial'.

The authors warned that patients could be receiving unnecessary tests - potentially resulting in avoidable stress for patients as well as increased workload for GPs and other primary care staff. 

The report warns: 'Unnecessary testing in a low prevalence setting such as primary care is more likely to lead  to false positives, which in turn can lead to cascades of follow-up testing. This can generate anxiety for patients, increased workload for doctors, and increased costs for the health service. False negative results, on the other hand, may lead to false reassurances and delayed diagnosis.'

The research team searched a database of international clinical trials and found ‘no studies looking at the question of how often patients with these chronic conditions should be tested’ in the pipeline.

Long-term conditions

Lead author Dr Martha Elwenspoek said: ‘Our review has shown a need to develop new, rigorous methods to enable evidence-based monitoring of chronic diseases in primary care.

‘The lack of evidence to inform the guidelines isn’t that surprising, as it’s a difficult area to test with traditional study methods. It wouldn’t be ethical to only test one group of patients and not test another group with the same long-term condition, for example.’

Dr Jessica Watson, a GP and co-author of the study, said: ‘When we spoke to patients about this, there was a misconception that all test results are completely reliable and that more testing is generally a good thing. So it’s important for GPs, and the nurses and other practice staff who carry out these tests, to have an open discussion with the patient.

‘Given this uncertainty around testing, health professionals should explain the drawbacks of testing as well as the benefits, so that the patient can make an informed decision. It’s also really important that GPs don’t over-use this kind of testing, doing tests "just in case" or because they’ve already taken blood for something else. This may seem efficient but can have consequences for the patient that aren’t immediately clear.’

This follows a study published in the BMJ last year, which found that the number of diagnostic tests and scans ordered by GPs has more than tripled in the past 15 years, with significant implications for GP workload.

The researchers estimated that the average GP now spends 1.5 to 2 hours reviewing test results each workday and highlighted that greater test use could lead to more consultations. ‘Our results support other evidence that suggests general practice workload in the UK is reaching saturation point,’ the study said.

Meanwhile, a report from the RCGP published earlier this year found that prevalence of long-term conditions is rising - with half of GP appointments going to patients with at least one chronic condition.

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