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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Adherence to Guidelines in General is Disappointing
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Natalie E. Ceccato, Toronto, Ontario CANADA University of Toronto, Lorraine E. Ferris, Professor of Public Health Sciences, University of Toronto
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This study makes an important contribution to understanding the relationship between evidence-based tool use and patient outcomes. Examining factors associated with guideline use (e.g. flow sheets) is a key step for improving our understanding of guideline utilization in primary care settings. One of the striking findings is that regardless of whether the diabetes flow sheet was used, adherence to the guidelines was low and likely clinically significant. We agree with the authors about the low adherence scores for target attainment, however, it is also worth looking at the adherence scores for assessment as 50.13 to 55.38 is disappointing. Arguably, 74.71 to 79.59 for treatment may be unsatisfactory and worthy of attention as well. It is Hahn et al’s innovative methodology of generating scores to reflect processes and outcomes that has made it possible to identify these important findings <1>. We all know there are no easy answers on how to increase uptake of clinical guidelines. We have previously discussed how guideline development and dissemination are key steps in the process of physician change however, knowledge through dissemination is not sufficient. Identifying factors that influence the implementation of practice tools (e.g. guidelines) including perceptions of the guideline itself, knowledge, beliefs, attitudes, and other motivational factors (e.g. confidence to implement) among stakeholders with consideration of the practice context (e.g. size, ownership, patient load) are important pieces of the process <2>. Once significant variables are identified, strategies can be systematically selected and implemented to target these facilitators and barriers. Identifying and addressing a few variables will not automatically make it possible to implement tools effectively; rather what is needed is a systematic approach of assessing the user population and practice setting (e.g. staff, technology) in addition to the tool itself <2>. There are many innovative studies that aim to understand factors associated with the uptake of clinical guidelines and some important intervention studies in this area. We hope the authors of this paper will continue with their important work. The authors point to the need for additional research “to explore patient and physician variables that mediate the relationship between use of the diabetes flow sheets and intermediate outcome targets for diabetes”. We wonder if perhaps the focus ought to be on the relationship between patient and physician variables with adherence to the NDEP guidelines since the differences between the flow sheet and no-flow sheet groups were small and both process and outcome targets for diabetes seem to warrant attention. Natalie E. Ceccato (MSc). Dept of Public Health Sciences, University of Toronto Lorraine E. Ferris (PhD., C.Psych., LL.M). Dept of Public Health Sciences, University of Toronto; Clinical Epidemiology Unit, Sunnybrook Health Sciences Centre, Toronto, Ontario, CANADA References 1. Hahn Karissa A, Ferrante Jeanne M, Crosson Jesse C, Hudson Shawna V, & Crabtree Benjamin F. Diabetes Flow Sheet Use Associated with Guidelines Adherence. Ann Fam Med 2008;6:235-238. 2. Ceccato Natalie E, Ferris Lorraine E, Manuel Douglas & Grimshaw Jeremy M. Adopting Health Behavior Change Theory Throughout the Clinical Practice Guideline Process. Journal of Continuing Education in the Health Professions 2007; 27:201-207. Competing interests: None declared |
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