Implementation of evidence-based treatments: the role of guidelines and recommendations:
The risk to develop a first or recurrent manifestation of atherosclerotic disease can be lowered by changes in lifestyle and by pharmacotherapeutic interventions. The Euroaspire I and II studies have demonstrated that a more complete implementation of existing guidelines will increase life expectancy and quality of life in most European countries.
Guidelines, recommendations, and expert consensus documents are all intended to help the clinician choose the appropriate therapy for a patient with a certain medical condition. As a rule such documents are based on the evidence provided by the outcome of controlled clinical trials or, if this is not available, on consensus between experts.
Despite the fact that guidelines and recommendations exist for the treatment of most common conditions in cardiology, it has been found in national and international hospital-based surveys, that many patients do not receive the therapy appropriate for their condition. On the other hand, several small and large outcomes studies show that under well-controlled conditions almost all patients may well receive appropriate therapy. The guideline developers use the term "implementation" as indicating the goal that each patient receives treatment in accordance with the existing guideline for the diagnosis under consideration, unless a medical reason exists to withhold the appropriate therapy. In this sense, implementation is either complete or incomplete.
Barriers to the implementation of evidence-based treatment guidelines:
Incomplete implementation of the appropriate therapy may have several causes. Some causes have to do with inadequacies of medical management, some with circumstances not within control of doctors, and sometimes the patient just does not fit the profile. Recently, three types of barriers to the implementation of evidence-based treatment guidelines have been suggested: a physician-related, a patient-related, and a healthcare-related barrier. [Refer to table 26 in the original guideline document for more detail on these barriers].
- Physician-related barriers to the implementation of evidence-based treatment:
Lack of knowledge of the existence of a particular guideline may result in the application of a less then appropriate therapy. It is of great importance that the existence of guidelines is widely communicated and that existing guidelines are easily accessible. The Internet provides an excellent tool, but it is also conceivable that guideline information is installed in smaller hand-held devices. Still, the physician has to develop the routine to check the guideline when a new diagnosis is to be matched by therapy. At the same time, the guideline-providing institution has the responsibility to ensure that existing guidelines are up-to-date as well as state-of-the-art.
A guideline is based on the available scientific evidence. The guideline, however, does not necessarily always fit the situation of a given patient. Even under ideal circumstances, the guideline may be difficult to interpret. On top of this, a guideline may be difficult to interpret because of unwanted ambiguity. The communicative aspects of any guideline should be given sufficient attention.
When the availability of time is the critical factor, as will be the case in many hospitals and primary care practices, and when guideline application is not part of an established routine, patients may not always receive guideline-conformed medical care.
Lastly, a physician can have good reasons to withhold the therapy suggested by a guideline. Or the patient may have reasons to refuse a certain treatment. The available reports on the implementation of guidelines give little information on the underlying rationale for not following the guideline.
- Physician-related methods to improve implementation:
A systematic review of the literature executed several years ago concludes that the application of guidelines in a setting of rigorous control gives the best chances to improve clinical practice. A recent study of the care of patients with acute myocardial infarction concludes that the "implementation of guideline-based tools may facilitate quality improvement among a variety of institutions, patients and caregivers." The shared conclusion here is that a guideline in itself is not the ultimate instrument to improve clinical care. The guideline needs a tool, or a setting, to realise its full potential.
One way to implement a guideline in a well-defined clinical setting, for example the treatment of acute coronary syndromes, can be to use the daily multidisciplinary group rounds. Another way is to create a "tool kit" and engage nurse and physician opinion leaders as well.
Treatment protocols, developed from evidence-based guidelines, can be used in circumstances where strict adherence to the rules for limited periods of time is essential for the quality of the care, for example in the intensive care unit.
A novel way to implement guidelines in patients with uncomplicated illnesses who are undergoing procedures or surgery is the use of critical pathways. Critical pathways are management plans that "display goals for patients and provide the corresponding ideal sequence and timing of staff actions for achieving those goals with optimal efficiency". Recently, the use of critical pathways for the implementation of evidence-based treatments has been critically reviewed. At this moment, more research into the added value of the use of critical pathways, clearly is necessary.
- Patient-related options to improve implementation:
Patient-related barriers to implementation in which the physician can play a role are related to polypharmacy and compliance with medication and to behavioural changes. For behavioural changes in particular, the reader is referred to the chapter on "Behaviour change and management of behavioural risk factors" in the original guideline document.
- Health care-related barriers to the implementation:
Some of the health care system—related barriers cannot be changed by the individual physician for whom these guidelines are written; others can be influenced by a better organisation in primary care practice and in the hospital.
The role of the National Societies:
The members of the Third Joint Task Force on Cardiovascular Disease Prevention in Clinical Practice expect that the National Societies and individual physicians will be actively engaged in the process to make these guidelines (or adapted ones) part of the standard daily clinical practice.
The Third Joint Task Force also fully subscribes to the need of a continuous evaluation of the relation between guideline developments, implementation programmes, and daily practice as addressed by the European Society of Cardiology.
