Click Here!

  eMJA     The Medical Journal of Australia

Home | Issues | eMJA shop | Classifieds | Contact | More... | Topics | Search | Login | Buy full access   

Local impact of the NHMRC early breast cancer guidelines: where to from here?

Jeanette E Ward, John Boyages and Leena Gupta

Subsequently cited in Dwyer P. Legal implications of clinical practice guidelines. MJA 1998; 169: 292-293.

Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company
Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>".

Abstract - Introduction - Methods - Results - Sample characteristics - Recall of and reactions to the guidelines - Self-reported use and views of impact on clinical practice and patient outcomes - Discussion - Acknowledgements - References

Make a comment - Register to be notified of new articles by e-mail - Current contents list - ©MJA1997

 

Abstract

 Obj ectives: To determine clinicians' recall of the National Health and Medical Research Council's (NHMRC) Clinical practice guidelines for the management of early breast cancer six months after publication, and their reactions to its content and potential dissemination and implementation strategies.
Setting: Greater Western Region of Sydney, May 1996.
Method: Self-administered survey of clinicians with an involvement or interest in the management of women with breast cancer.
Results: Of the 69 respondents to the questionnaire (77% response rate), 20% did not recall ever seeing the guidelines. Although most agreed with the defined parameters of potential strengths of the guidelines, there was less agreement as to their medicolegal implications. The four treatment sections of the guidelines were the most highly rated, followed by the sections on communication skills and investigations. Education programs, including college-based programs, as well as endorsement of the guidelines by the learned colleges and respected colleagues, were rated highly as dissemination strategies, far outranking Internet availability. Local revision of the guidelines was considered important as an implementation strategy by three-quarters of respondents. Only 20% indicated that the guidelines had influenced clinical practice, although 46% agreed that they would improve outcomes for women with early breast cancer.
Conclusions: The NHMRC early breast cancer guidelines have been relatively well received in the Greater Western Region of Sydney, although local activities within public institutions and private practice will be needed to achieve implementation .

MJA 1997; 167: 362-365  

Introduction

 Evidence-based clinical guidelines have been advocated by overseas1-3 and local4 authorities to support more effective health care and enhance patient outcomes. However, publication of guidelines alone is insufficient to ensure improvements in clinical practice because dissemination and implementation of guidelines must follow if patient outcomes are to improve.5

Although there is evidence of increased activity in the development of evidence-based guidelines in Australia, dissemination and implementation of such guidelines have received less emphasis.6 Dissemination refers to activities which encourage positive attitudes toward specific guidelines and raise awareness of the need to change. Strategies appropriate to disseminate guidelines include medical seminars about the guidelines and endorsement by recognised peers.7 Implementation refers to activities which aim to achieve and maintain changes in actual practice. Strategies to implement guidelines include audit and feedback, prompts for clinicians, checklists for patients, and financial sanctions and incentives.7,8

The Clinical practice guidelines for the management of early breast cancer9 were the first guidelines produced by the National Health and Medical Research Council (NHMRC) using an explicit evidence-based process.10 The guidelines, published in 1995, were designed "to assist in decision-making by women and their doctors, educate all involved in the care of women with breast cancer, assess and assure the quality of care, reduce the risk of legal liability by improving care and bring the issue of cost-effectiveness into the public arena".10 A consumer guide was also published at the same time.11 We wished to determine clinicians' recall of the guidelines six months after national distribution as well as their reactions to its content, and potential dissemination and implementation strategies.  

Methods

 In May 1996, we mailed an eight-page questionnaire and a copy of the guidelines, after an advance telephone prompt, to all members of the Western Areas Breast Group in the Greater Western Region of Sydney, encompassing the Western, Wentworth and Southwestern area health services (n = 52), all other clinicians known to have managed women with breast cancer in 1992 in the region12 (n = 27), and surgical and oncology registrars (n = 11). Non-respondents were followed up with reminder letters a fortnight later and a telephone call 26 days later by one of us (J E W) and 70 days later by an eminent peer.

The questionnaire was designed to assess recall and recent use of both the guidelines and consumer guide and the impact of the guidelines to date. We asked respondents to rate eight potential strengths of the guidelines and seven potential criticisms using a five-point scale (strongly agree, agree, unsure, disagree, strongly disagree). To assess content relevance, we asked respondents to rate the usefulness of information in 12 sections of the guidelines using five categories (very, somewhat useful, not useful, unsure, not applicable).

To assess the influences on clinicians' decisions whether to follow the guidelines, we asked respondents (using the same response options) to rate the relative importance of each of four features of the development process, one current and five potential dissemination strategies, and three implementation strategies. The latter consisted of a regional implementation strategy designed around revision of the guidelines by all western Sydney specialists to enhance its local application as well as two other implementation strategies drawn from the international literature7,8 (namely, an interactive computerised system to provide clinicians with individualised feedback about patterns of care, and patient checklists provided directly to women).

Eight questions ascertained respondents' sociodemographic and professional characteristics.  

Results

  

Sample characteristics

 We obtained a 77% response rate (90 clinicians received questionnaires and 69 returned them). Of the 69 respondents, 59 (85%) were men and 10 were women (14%), and ages ranged from 26-67 years. The sample consisted of 35 general surgeons (51%), 10 breast surgeons (14%), five medical oncologists (7%), seven radiation oncologists (10%), and nine registrars (13%) (a further three did not specify). The number of new patients with breast cancer seen per respondent per month ranged from 0-20 (mode, 1; median, 2).

Involvement in teaching and research was reported by 52 (75%) and 29 (42%), respectively. Over half the respondents had Visiting Medical Officer appointments (n = 39; 56%), and 18 (26%) were full-time staff specialists in public hospitals. Eight breast surgeons (80%) and 16 general surgeons (46%) were associated with the Royal Australasian College of Surgeons Breast Section.  

Recall of and reactions to the guidelines

 Fifty-five respondents (80%) indicated they had seen the guidelines before receiving a copy with our survey, while 12 (17%) had commented on the earlier draft circulated for consultation in June 1995. Only 35 (51%) were aware of the Consensus Statement on the Management of Breast Cancer, published by the Clinical Oncological Society of Australia.13 Fifty-one respondents (74%) were familiar with the consumer guide, but only 12 (17%) always recommended it to women; 20 (29%) sometimes and five (7%) rarely. A further 25 (36%) did not recommend it at all. Of the 37 who recommended the consumer companion, only two would document this always in their medical records; two sometimes and one rarely. The rest never recorded it.

Box 1 shows that at least three-quarters of respondents had positive views (strongly agree or agree) for five out of eight statements about potential strengths of the guidelines. More than half disagreed or strongly disagreed with five of seven potential criticisms of the guidelines. While 32% were unsure if the guidelines could be used to sue doctors, 45% agreed or strongly agreed that they could.

Box 2 summarises respondents' ratings of specific sections of the guidelines. The four sections listed in the questionnaire about treatment decisions were the most highly rated, followed by the section on communication skills, which outranked the seven sections concerning investigations and other pretreatment decisions.

All four features of the guidelines development process were very or somewhat important for almost all of the respondents in deciding whether to follow their recommendations (Box 3). To disseminate the guidelines, most respondents rated educational programs conducted by learned colleges (84%) as well as their endorsement of the guidelines (86%) as very or somewhat important strategies. Other educational programs and recommendation by a respected colleague were rated as very or somewhat important by nearly three-quarters of respondents and outranked Internet availability (the only dissemination strategy in place at the time of the survey). To implement the guidelines, local revision by specialists to make the guidelines more practical was ranked by 76% as being either very or somewhat important in deciding whether to follow the guidelines, contrasting with respondents' ratings of an interactive computer system (50%) and patient checklists (34%).  

Self-reported use and views of impact on clinical practice and patient outcomes

 Forty-one (59%) respondents had not referred to the guidelines at all in the previous month of practice, 20 (29%) had referred to them between one and four times, and seven (10%) more than four times. Of the 38 respondents who indicated they saw at least one new patient each month, 34 (90%) had not referred to the guidelines at all in the previous month. Forty-two (61%) respondents indicated that the guidelines had had no influence on their clinical practice, 14 (20%) indicated that they had, and three (4%) were unsure (data missing or the guidelines had not been seen by the remainder).

In response to the question Will the guidelines improve outcomes for women with early breast cancer?, 32 (46%) indicated "yes", while 11 (16%) indicated "no", and 25 (36%) were unsure.  

Discussion

 Our study assessed the initial reactions of a multidisciplinary group of clinicians to the first evidence-based clinical practice guidelines produced by the NHMRC. Most respondents (80%) had seen the guidelines six months after publication. This compares well against previous surveys showing much lower recall of other national guidelines (e.g., among general practitioners),14 and exceeds the proportion recalling earlier guidelines produced by the Clinical Oncological Society of Australia.13

Even clinicians who recalled the guidelines appear not to have been substantially influenced by them. However, it is possible that clinical practice was already consistent with evidence-based best practice. However, this explanation is inconsistent with the fundamental premise underpinning initiation of the guidelines9 and other, indirect, evidence of an unacceptable variation in practice.12,15 In addition, the guidelines (and a parliamentary report16 ) recommend that clinicians advise their patients about the availability of the consumer companion and recommend them as a reference to be used in cooperation with their doctor.9 However, more than a third of respondents did not recommend the consumer guide at all.

Guidelines will not change practice unless clinicians have access to them when needed. Our study shows that use of the guidelines at the local level appears limited. A planned approach to dissemination and implementation is needed. Respondents' ratings of potential strategies have identified useful priorities. Their views on potential dissemination strategies ought to be used to find ways to encourage positive attitudes toward the guidelines and, through their preferred implementation strategies, to change behaviour.

Respondents' interest in educational programs conducted by learned colleges, as well as colleges' endorsement of the guidelines, suggests the use of these strategies to create a greater interest in the guidelines. To achieve full implementation, however, local adaptation will be critical.18 Local adaptation will engender a stronger sense of ownership of the guidelines, but mechanisms to enssure the methodological integrity of the evidence-based elements of the guidelines throughout the process of local adaptation will need to be developed. As implementation strategies shown to be effective in overseas research received low ratings in our survey, they should be replicated in controlled trials before being given wider advocacy. Given the relative lack of experience in Australia to date in disseminating, implementing and monitoring use of evidence-based guidelines,17 documentation of the process of local implementation of the guidelines is needed. Finally, as measurement of improved patient outcomes represents the "gold standard" of guidelines evaluation,4,19 we recommend such an approach at local, State and national levels.  

Acknowledgements

 We thank all who completed the questionnaire; Professor Allan Langlands and staff of the Breast Cancer Institute for commenting on draft questionnaires; Dr Kate George for telephone prompts; Ms Josette Banks and Mrs Nancy Harding for survey administration; Emeritus Professor Tom Reeve for generous contribution to telephone follow-up; and Mr Md Moniruzzaman for data analysis.  

References
  1. Field M, Lohr K. Guidelines for clinical practice: from development to use. Washington: National Academy Press, 1992.
  2. Grimshaw J, Russell I. Achieving health gain through clinical guidelines: 1. Developing scientifically valid guidelines. Qual Hlth Care 1993; 2: 2432-2438.
  3. Hayward RSA, Laupacis A. Initiating, conducting and maintaining guidelines development programs. Can Med Assoc J 1993; 148: 507-512.
  4. National Health & Medical Research Council. Guidelines for the development and implementation of clinical practice guidelines. Canberra: AGPS, October 1995.
  5. Grimshaw J, Russell I. Achieving health gain through clinical guidelines II: ensuring guidelines change medical practice. Qual Hlth Care 1994; 3: 45-52
  6. Holt P, Wilson A, Ward J. Clinical practice guidelines and critical pathways: a status report on national and NSW development and implementation activity. Sydney: NSW Health Department, 1996: 106.
  7. Grimshaw J, Russell I. Effect of guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342: 1317-1322.
  8. Davis D, Thomson M, Oxman A, Haynes RB. Changing physician performance: a systematic review of the effect of CME. JAMA 1995; 274: 700-705.
  9. National Health and Medical Research Council. Clinical practice guidelines for the management of early breast cancer. Canberra: AGPS, 1995.
  10. Smallwood R. President's letter. RACP Fellowship Affairs 1996; 15: 3.
  11. National Health and Medical Research Council. Early breast cancer. A consumer's guide. Canberra: AGPS, 1995.
  12. Western Areas Breast Group. Breast cancer patterns of care in the Greater Western Region of Sydney in 1992. Sydney: NSW Breast Cancer Institute, 1997: 1-98.
  13. Breast Cancer Consensus Report. Med J Aust 1994; 161 (Suppl): S1-S16.
  14. Gupta L, Ward J, Hayward R. Clinical practice guidelines in general practice: a national survey of recall, attitudes and impact. Med J Aust 1997; 166: 69-72.
  15. Adelson P, Lim K, Churches T, Nguyen R. Surgical treatment of breast cancer in NSW, 1991-1992. Aust N Z J Surg 1997; 67: 9-14.
  16. 16. House of Representatives Standing Committee on Community Affairs. Report on the management and treatment of breast cancer in Australia. Canberra: AGPS, February 1995: 133.
  17. Ward J. Best practice guidelines implementation -- implications for patient outcomes. Proceedings of the Second Conference of the Australian Health Outcomes Clearing House. Integrating health outcomes measurement in routine health care; 1996 Aug 13-14; Canberra. Canberra: AHOCH, 1997: 78-83.
  18. Browman G, Levine M, Mohide E, et al. The practice guidelines development cycle: a conceptual tool for practice guidelines development and implementation. J Clin Oncol 1995; 13: 502-512.
  19. Thompson R, Lavender M, Madhok R. How to ensure that guidelines are effective. BMJ 1995; 311: 237-242.

(Received 8 Jan, accepted 3 July, 1997)

Author's Details

Needs Assessment & Health Outcomes Unit, Central Sydney Area Health Service, NSW.
Jeanette E Ward, PhD, FAFPHM, Director;
Leena Gupta, MPH, FAFPHM; formerly, Clinical Epidemiologist (Cancer Outcomes).

NSW Breast Cancer Institute, Western Sydney Area Health Service, NSW.
John Boyages, FRACR, PhD, Director.

Reprints: Dr J E Ward, Needs Assessment & Health Outcomes Unit, Central Sydney Area Health Service, Locked Bag 8, Newtown, NSW 2042.

Home | Issues | eMJA shop | Terms of use | Classifieds | More... | Contact | Topics | Search

The Medical Journal of Australia    eMJA  

©MJA 1997

<URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.
We appreciate your comments.