Introduction

Guidelines have been defined as 'systemised statements designed to assist clinicians in managing patients'. However, their use is not always straightforward. They can be used for assisting clinicians with clinical decisions, as standards for determining the quality of care, and as part of wider processes for improving the quality of care. In a perfect world guidelines would be unnecessary, clinicians would obtain the best available evidence relevant to each patient's problems at each point in time, and use it in their practice.

There are disadvantages to the use of guidelines as well as advantages. Before deciding to what extent we should embrace or repel them - let alone how we should do so - it is important first to look at the context in which guidelines are used.

Guidelines and evidence-based medicine

Guidelines are designed to help clinicians do the right thing. However, this means we have to define what 'the right thing' is. Evidence-based medicine, the process of obtaining and using the best available evidence from research, clearly has a central role although evidence is lacking for many areas of clinical practice. Originally developed as a process to provide the clinician with the information with which to make decisions, it has been seized upon by the makers of guidelines to ensure that their guidelines are optimal. Guidelines are not necessarily evidence-based (in the past, they were often only 'consensus-based'), but the best ones are evidence-based.

Guidelines as standards

What about clinicians who do not adhere to a guideline? Guidelines have changed their function from being something designed to assist clinicians in managing patients, to become a standard. For example, the National Breast Cancer Centre commissioned guidelines for the management of women with a new symptom in the breast. These guidelines were studied not only to decide if they changed doctors' behaviour (they did when the education was combined with an audit), but also as benchmarks to make judgements about the doctors' standard of care.1 The National Prescribing Service has also encouraged audits of antibiotic prescribing in which guidelines have been used as the standard against which judgements can be made.

Standards can be set at several levels: minimal, normative and exemplary.2 Each has its own uses. Minimal standards can be used to identify health professionals who perhaps require remedial or even punitive action. Exemplary standards aim to encourage the whole profession to improve. It is clearly important to recognise which level should be applied to any guidelines that will be used as a standard.

Guidelines and quality of care

Guidelines can be used to improve the quality of care. They can help clinicians who want to know what to do. This can be amplified into a wider process such as 'quality assurance', 'quality improvement' and more recently 'clinical governance'. These all involve a cycle of selecting an area of care, measuring this against guidelines as a standard, and then changing management to address any discovered shortcomings. However, the notion of 'guidelines-as-standards' as a means of reducing 'clinical variation' may be flawed.

First, variations in care do not necessarily imply variations in quality. There are many situations in which one form of care is as good as another. A good example comes from the use of antibiotics for acute otitis media.3 The benefits of antibiotics are marginal and may be counterbalanced by the adverse effects. In other words, symptomatic treatment with or without a prescription for antibiotics may be equally good quality care.

Secondly, guidelines imply that one size should fit all. In some situations this is likely to be correct. For example, a breast lump in a woman 65 years old needs to be properly investigated in a specialist clinic until malignancy has been excluded. However, there will always be some people who do not fit the guidelines. General practitioners are experts at finding the right treatment for their patients. This involves taking account of their psychosocial factors and welding different pieces of information together to make a decision.4 A woman might have a phobia of needles that would make fine-needle aspiration of her breast a serious problem; she may also have other more pressing and urgent medical or non-medical problems that assume a greater priority. Being sensitive to these issues may actually be a sign of very good quality care. Patients' views (if well informed) may be as important a factor in deciding what to do as the evidence on which guidelines are based.

E-mail: c.delmar@cgp.uq.edu.au

Further reading

Some guidelines can be accessed through the following web sites:

http://www.guideline.gov/ (US National Guidelines clearinghouse)

http://www.health.gov.au/ (Commonwealth Department of Health and Aged Care - a good starting point for several other sites)

http://www.nhmrc.health.gov.au/ (National Health and Medical Research Council)

http://www.healthinsite.gov.au/ (A federally-funded information site about health)

http://www.ctfphc.org/ (One of the best sites on preventive health care, from the Canadian Task Force)

http://www.tg.com.au (Therapeutic Guidelines) (available at cost)

(Note: Three members of the Australian Prescriber Executive Editorial Board, Doctors R.F.W. Moulds, J.W.G. Tiller and J.S. Dowden, are unpaid directors of Therapeutic Guidelines Ltd., a not-for-profit organisation.)

References

  1. Pit S, Cockburn J, Zorbas H. Investigation of a new breast symptom: an audit in general practice. Sydney: NHMRC National Breast Cancer Centre; 1999.
  2. Bridges-Webb C, Butler J, Calcino G, Colmer P, Del Mar C, Dickinson J, et al. General practice in Australia: 1996. Canberra: General Practice Branch, Commonwealth Department of Health and Family Services; 1996.
  3. Glasziou PP, Hayem M, Del Mar CB. Antibiotics for acute otitis media in children [review]. In: The Cochrane Library. Oxford: Update Software; Issue 2, 2000.
  4. Stewart M. Healing partnerships between patients and family doctors: an aspect of quality of care. Working paper series #98-1. Ontario: Centre for Studies in Family Medicine, The University of Western Ontario; 1998.