Solving the information overload problem: a letter from Canada

The gap between what doctors might do (based on evidence-based clinical practice guidelines [CPGs]) and what they actually do is wide, variable1 and growing. Many factors contribute to this situation. Doctors are inundated with new, often poorly evidence-based and sometimes conflicting clinical information. This is particularly serious for the generalist, with over 400 000 articles added to the biomedical literature each year. Adding further pressure to the “gap” are workloads that have increased over the past decade: doctors are seeing more patients with acute and complex conditions.2 Canadian medical practitioners feel that they are on a “medical treadmill”, working an average of 53.8 hours per week.3 Rural practitioners work even longer hours, offer more medical services and perform more clinical procedures than their urban counterparts4 — thus facing an even greater need for up-to-date information.

Compounding this problem is another: there is good evidence that what we do in continuing medical education (CME) (produce courses, give didactic lectures, mail unsolicited printed materials) is not very effective in changing physician behaviour.5-7 Interventions that do show promise (such as reminders at the point of care, assistance of opinion leaders, academic detailing, feedback on performance) are uncommon and not well used by policymakers, CME providers and others.

Thus, doctors are faced with many challenges to practising optimal care. There is too much, often conflicting, information that is not easily digestible, insufficiently evidence-based, and not delivered in a timely, effective or coordinated manner. To address some of these challenges, the Ontario Guidelines Advisory Committee (GAC) has adopted a best-practice guideline strategy to support doctors in their endeavours to practise high-quality care. Here we briefly describe the GAC’s evidence-based guideline search, review and endorsement processes across the spectrum of clinical practice. We then focus on two specific clinical areas to illustrate the type of work we do to promote appropriate practice performance.

Guideline topics include a wide variety of primary-care topics generated by the committee members and by sections within the Ontario Medical Association, as well as more specialised topics (eg, the appropriate use of echocardiography, pelvic ultrasound and hyperbaric oxygen therapy). Once a clinical topic is identified, a systematic search of medical literature databases and Internet-based guideline sites is conducted. Guidelines so identified are then sent to trained physician reviewers throughout the province for peer review, using a validated assessment tool, the AGREE (Appraisal of Guidelines Research and Evaluation) instrument.8 Currently, the GAC has a bank of over 50 trained doctors to assist in the guideline review process. Each guideline is assessed by a minimum of three reviewers; guideline assessments are aggregated and given an “apple” rating — four apples denoting an excellent guideline. The review process allows for an evidence-based method to assess the quality of CPGs, identifies potential bias in the guideline development process and ensures that the recommendations are both internally and externally valid. The AGREE instrument is also useful in critically evaluating the methods used for developing the guidelines, the content of the final recommendations, and the factors linked to their uptake.

Using these assessments, the GAC further reviews the guidelines based on its medical expertise, its knowledge of the Ontario healthcare system and the recency of the guideline. The Committee then recommends the most timely, relevant and evidence-based CPGs for uptake by doctors in Ontario. As at September 2003, GAC medical reviewers had reviewed 448 individual guidelines, and 56 best-practice guidelines had been endorsed.

To help with the time challenges facing Ontario doctors, the GAC summarises recommended CPGs into usable one- to two-page summaries (posted on the GAC website9 and featured monthly in the Ontario Medical Review, published by the Ontario Medical Association). The GAC website also provides electronic links to clinical decision tools, algorithms and patient educational materials, where they exist. As an additional method of raising physician awareness of GAC recommendations, the GAC showcases a tabletop presentation of its work at many functions organised by the Ontario Medical Association and other partner organisations.

The GAC and its partner organisations (Box 1) have undertaken a plan to implement best practice in two areas: (a) preoperative testing, and (b) managing acute low back pain. Both plans recognise that, although single guideline education initiatives are most common, simple to plan and least expensive to implement, multiple, concurrent guideline implementation activities are more effective.6,10 The methods used in each of the two clinical areas are shown in Box 2.

In making any evaluative comments about the GAC process and plans, it is necessary to be cautious about interpreting the impact of the project. First, the manner in which guideline review and endorsement is undertaken is imperfect, including the application of the AGREE instrument. Second, the research on which the guideline implementation and endorsement strategies is based is imperfect at best,22 and the way in which we have been able to roll out the plans has been moulded by practical and practice realities, well beyond the scope of our project, and not easily amenable to formal, objective evaluation. Third, the measures we intend to use to assess the impact of our efforts — a province-wide pre- and post-guideline-implementation data analysis of hospital utilisation of routine preoperative electrocardiograms and chest x-rays and of lumbosacral spinal x-rays — have not yet been completed. Rates of change in the use of these tests will be used as a proxy to measure the GAC’s success at implementing guidelines and changing physicians’ behaviour, but we recognise that these are crude measures, insensitive to many practice and practitioner realities.

Nonetheless, through the work of the GAC, the Ontario Ministry of Health and Long-Term Care and the Ontario Medical Association have demonstrated their commitment to the physicians of Ontario and to the endorsement of useful and provincially approved guidelines. Further, through its implementation planning and execution, the Ontario Guideline Collaborative has engendered goodwill and garnered support for an evidence-based guideline endorsement and implementation program. Perhaps the clearest sign of success is that the GAC and its collaborative efforts exist at all, aiming to improve the adoption of best evidence by Ontario’s medical practitioners.