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Document: 7
The effects of clinical practice guidelines on patient outcomes in primary
care: a systematic review.
Worrall G, Chaulk P, Freake D..
The effects of clinical practice guidelines on patient outcomes in primary
care: a systematic review.
Canadian Medical Association Journal,
1997,
156(12),
pp.1705-1712
Record status
This record is a structured abstract written by CRD reviewers. The original
has met a set of quality criteria. Since September 1996 abstracts have been
sent to authors for comment. Additional factual information is incorporated
into the record. Noted as [A:....].
Author's objective
To assess the evidence for the effectiveness of clinical practice guidelines
(CPGs) in improving patient outcomes in primary care. Type of
intervention
Management/Clinical practice guidelines.
Specific interventions included in the review
Clinical practice guidelines relating to medical conditions normally treated
by family physicians. The most common conditions examined in the included
trials of guidelines were hypertension, asthma and cigarette smoking.
Participants included in the review
Primary care physicians. US studies carried out in internal medicine clinics
which appeared to offer primary care services were included, as well as
studies carried out in countries with a clear primary care system.
Outcomes assessed in the review
Any clinical patient outcomes reported in the primary studies were included.
These varied according to the type of guideline and medical condition studied,
and included reduction in blood pressure in studies of hypertension; smoking
cessation or abstention; fasting plasma glucose, glycated haemoglobin, and
weight and blood pressure (in a study in diabetic patients); asthma morbidity
(asthma management study); blood pressure, weight and % of patients with
normal renal function, urinalysis and culture (study of hypertension, obesity
and renal disease). One study also examined the management of a range of
conditions, including bedwetting, acute cough, rash and wheezing, with a
similarly wide range of outcomes (e.g. reduction in bedwetting,
breathlessness, and reduction in days wheezy).
Study designs of evaluations included in the review
Randomised experimental or quasi-experimental trials. However two studies
involved non-random assignment of physicians. One before and after study with
a replicated latin-square design was also included. The length of follow-up
in these studies ranged from 11 months to 30 months.
What sources were searched to identify primary studies?
MEDLINE, HEALTHPLAN, CINAHL, FAMLI, from 1980 to 1995. Search strategy given.
The bibliographies of 3 articles about CPGs were also examined.
Criteria on which the validity (or quality) of studies was assessed
A six point scale was used, based on the method of Sackett and associates.
This used the following criteria: was the assignment really randomised? Were
all clinically relevant outcomes reported? Were the study patients
recognisably similar to your own? Were both clinical and statistical
significance reported? Is the therapeutic manoeuvre feasible in your practice?
Were all the patients who entered the study accounted for?
How were the judgements of validity (or quality) made?
Not stated.
How were decisions on the relevence of primary studies made?
Not stated, but studies had to relate to primary care patients with diagnosed
medical conditions.
How was the data extracted from primary studies?
Not stated, though a list of all information extracted from each study is
included.
Number of studies included
13 trials, with a total of approximately 615 physicians (number not given in
two studies) and approximately 24999 patients (number not given in 2 studies).
How were the studies combined?
Narrative review.
How were differences between studies investigated?
Narratively (by discussion of the impact of methodological flaws on specific
trials).
Results of the review
5 of 13 (38%) studies showed significant improvements in outcomes as a result
of the use of CPGs. In these studies improvement was noted for only a
proportion of conditions studied, for only certain patient subgroups, or for
only a limited period. 4 of 9 studies of local guidelines produced significant
improvements, compared with 1 of 4 studies of national guidelines. 2 of 6
studies using computerised or automated reminder systems showed significant
improvements compared to 3 of 9 studies which relied on physicians' recall.
Was any cost information reported?
No.
Author's conclusions
The studies reviewed showed little evidence that CPGs are effective in
improving patient outcomes in primary care. Even when the change was
statistically significant, it was usually modest. There is need for more
research on guidelines that include measures of patient outcomes.
CRD commentary
Generally, a methodologically sound review which builds upon and updates
previous reviews in this area. However, as not all the primary studies were
randomised it is not clear that the guidelines were indeed responsible for any
improvements in outcomes. Improvements in outcomes may also have been due to
the method of implementation, as opposed to the guidelines per se.
Subject index terms
Subject indexing assigned by NLM: Practice-Guidelines/st [standards];
Primary-Health-Care/st [standards]; Randomized-Controlled-Trials/st
[standards]; Treatment-Outcome Canada-; Confidence-Intervals;
Data-Interpretation,-Statistical; England-; Evaluation-Studies;
Evidence-Based-Medicine; Follow-Up-Studies; Hypertension/pc
[prevention-and-control]; Information-Storage-and-Retrieval; MEDLINE-;
Research-Design; United-States
Correspondence address
Dr G. Worrall, Centre for Rural Health Studies, Community Health Centre,
Whitbourne NF AOB 3KO, Canada.
Copyright
University of York, 1998
Database no.: DARE-978218
