Practical clinical guidelines

Current situation

- Clinical guidelines have increasingly become a familiar part of practice.

- Guidelines should be practical and based on valid up-to-date evidence.

They should be easily accessible to practitioners and should be adapted to suit the target population.

- It is important to be aware of the level of evidence upon which a guideline is based.

- Guidelines should take into consideration the available resources needed for them to be implemented successfully.

What is the evidence?

- Ample evidence exists to support the argument that the most simple and cost-effective intervention to increase the implementation of guidelines is rewriting guidelines in behaviourally specific terms (BMJ 2004; 328: 343).

- One problem with guidelines is knowing which ones to use in clinical practice, because often different guidelines for the same condition have conflicting advice.

This was made apparent with the British Hypertension Society guidelines (BMJ 2004; 328: 634). Although they recommend tailoring antihypertensive drug choice according to a patient's ethic group and age (the ABCD approach), the NICE guidelines for hypertension initially conflicted with this. In February 2006, NICE stated beta-blockers should not be used as first-line treatment.

- The current guidelines for stroke emphasise the importance of lowering BP in people with a history of cerebrovascular disease, largely on the basis of the results of the PROGRESS trial (Lancet 200; 358: 1,033).

However, a study has shown that important differences exist between the participants in PROGRESS and a typical primary care population of people with cerebrovascular disease, undermining the applicability of the research findings (BMJ 2006; 332: 635).

Implications for practice

- The number of guidelines for UK doctors is at least 300 (BMJ 2006; 332: 793).

- NICE was established to advise the NHS, not only on the quality of care that individual patients could expect from the NHS - in terms of appropriateness and effectiveness - but also to address the other important dimensions of healthcare quality, such as equity, fairness and the efficiency that society expects.

- NICE has published 95 technology appraisals, 156 interventional procedures guidelines, 41 clinical and cancer services guidelines, and 93 health technology assessment reports.

- An editorial highlights the challenges that NICE and its advisory committees and development groups face on a daily basis (BMJ 2004; 328: 536).

- The cost-effectiveness of guidelines should be considered before comparing other cost-effective approaches (BMJ 2006; 332: 793).

USEFUL WEBSITES

www.nice.org.uk - NICE

www.sign.ac.uk - Scottish Intercollegiate Guidelines Network

- Dr Louise Newson is a GP in the West Midlands and author of 'Hot Topics for MRCGP and General Practitioners', Pas Test 2006

KEY POINTS

- Guidelines should be easy to use.

- There are many conflicting guidelines exist.

- Cost effectiveness of guidelines needs to be considered.

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