Asthma morbidity has been increasing1 and, until recently, so has asthma mortality.[2, 3] In addition, acute asthma has a disproportionate impact on overall health costs.4 To overcome reported differences in asthma management, clinical practice guidelines (CPGs) have been established to define optimum care,5 although they have not always received enthusiastic support.6 Some authors deride CPGs as a "cookbook" approach to patient care7; others suggest that CPGs might lead to medicolegal problems; and some think the art of medicine may be at risk.7 Despite these concerns, CPGs have evolved into a major component of health care.
Although CPG development is a challenging and demanding task,5 their implementation has proved even more problematic.8 Assessment of the national impact of asthma guidelines is difficult. After publication of the first Canadian asthma consensus statement in 1990,9 rates of asthma mortality declined significantly through the early 1990s.1 Prescribing data for the same period showed an increase in inhaled corticosteroids prescribed, but the number of units of β-agonists sold also continued to rise.10
Publication and even dissemination of guidelines does not ensure a change in physicians' practice. Investigators found that physicians' compliance with asthma guidelines was especially poor in terms of prescribing preventive medication and making routine objective measures of peak flow.11 Direct mailing of recommendations did not alter the prescription of estrogen in menopause.12 In Canada, a recent survey of a group of family practice physicians with a special interest in asthma revealed that only 47% of respondents were familiar with the 1995 guidelines (personal communication, Mervyn Dean, Family Practice Asthma Group, Corner Brook, Nfld.). It is likely that nonrespondents were even less aware of the 1995 guidelines. Thus, there is a need to do more to ensure a change in practice and, it is hoped, an improvement in the health of patients with asthma.
Despite the large volume of research on continuing medical education (CME) and interventions to improve professional practice,13 few studies assess all outcomes, particularly changes in patient care.14 Dodek and Ottoson15 argue strongly that implementation of CPGs and CME are very similar: they both aim at improving patients' well-being by changing physicians' behaviour. Many factors that influence implementation of CPGs and the effectiveness of CME are also similar: e.g., changes in behaviour, implementing organization, the actors involved, etc. Thus, it appears reasonable to apply successful methodologies of CME to CPGs.
A number of implementation strategies have been suggested (Table 1),16 and Grimshaw and colleagues5 have outlined some key principles for implementing CPGs. There appears to be no "magic bullet" for improving the quality of health care, but a wide range of interventions, if used appropriately, could lead to significant improvements in asthma management and outcomes13 (Table 2). Multiple interventions appear to be more useful than single ones.[13, 17] Traditional CME appears to be the least effective method for guideline implementation,17 and despite successful implementation, an effect on patients' health18 is not always guaranteed.
Local implementation of CPGs seems to work better than following externally formulated CPGs.19 However, existing national CPGs may still serve as a template.20 There is an important role for "academic detailing," in which key opinion leaders[13, 14] are to be involved in the implementation strategy. In a randomized controlled trial of guidelines using a practice-based educational strategy,21 a simple stamp on the patients' chart to remind the physician how to assess the patient was considered pivotal. Consensus conferences seem to influence at least the participants, who are capable and willing to change their initial recommendations when confronted with relevant data.22 Opinion leaders have been shown to influence the behaviour of others particularly during "teachable moments."23 Small-group learning in the form of case studies and workshops has been shown to be an effective way to teach and cause behavioural change.[14, 24] In France, the use of fines to encourage adherence to CPGs has been suggested,25 but such a policy entails high administrative costs.26
There is a need to study the various methods used in CME and apply appropriate ones in the implementation of CPGs. Also, randomized trials are needed to assess the effectiveness and cost of implementation strategies, in particular small-group, case-based learning. The latter is costly in terms of both time and money and may not reach enough people to be effective. Innovative strategies, such as educating the lay public, may have an effect, not only on the patient, but also on physician behaviour. In addition, there is a need to empower patients to control their disease, which can be achieved by providing a patient version of the guidelines.27 It is important to evaluate methods used in the implementation of guidelines.[28, 29]
Recommendations
• National guidelines should be adapted and implemented at a local level (level IV). This initiative could take the form of small-group problem-based workshops and case-based reviews, complemented by medical grand rounds. Workshops should focus on the practical day-to-day management issues, i.e., appropriate diagnosis, anti-inflammatory therapy, correct inhaler technique.
• The use of a stamp in asthma patients' charts has been shown to improve asthma care compared with no such intervention (level I).
• Key opinion leaders should be engaged to help promote asthma guidelines both as facilitators and as content experts for workshop programs (level IV).
• There is a need for further controlled trials to define more clearly the optimum strategies for guideline implementation and to evaluate the impact of asthma guidelines on the management of asthma, especially the effect on patient outcome. Ongoing audit and re-evaluation by various stakeholders, e.g., college of family physicians, government health groups, may be particularly important (level IV).
• A consortium of professional organizations, government, divisions of continuing medical education and industry should be encouraged to work together on implementing strategies to disseminate the recommendations. Industry, in particular, should be encouraged to collaborate in non-product-related programs that will make the best use of resources and prevent unnecessary duplication (level IV).
References
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