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It's a jungle out there
Doctors are getting lost in the
clinical guidelines maze -- and the message is too.
New kid steps in to do a mine sweep
By Giancarlo La Giorgia
Canada's medical organizations
need to do more to turn clinical practice guidelines
(CPGs) from theory into practice. That was the consensus
of physicians attending a March 12 workshop co-sponsored
by the Canadian Medical Association (CMA), Health Canada
and the Canadian Stroke Network, that brought together
experts in the field to discuss how CPG uptake in this
country could be improved.
The workshop's participants expressed
their frustration with the tendency of some Canadian
guidelines not to address the most common patient care
issues and urged the CMA and other organizations to
work more closely with guideline developers.
The message from across the country
seems to be that most doctors couldn't agree more. Dr
John Stewart is a GP in Port Perry, Ontario, who's been
involved in guideline development and implementation
for years. He shares his colleagues' dissatisfaction
with both Canadian guidelines and organizations like
the CMA and the Guideline Advisory Committee (GAC),
which provide access to guidelines but don't ensure
that they're practical or that they'll be used.
"Many [CPGs] are produced by experts
without family practice input. They focus on tertiary,
more complicated situations and tend to ignore the vast
bulk of primary care needed," he says.
Another major issue at the workshop
was the incorporation of current technologies -- personal
digital assistants (PDAs), electronic health records
(EHR) and the internet -- to facilitate regular guideline
usage.
Finding CPGs on the internet is
relatively easy if you know where to look -- a Google
search for "clinical practice guidelines" will produce
over 13,000 Canadian web pages alone -- but quantity
is a poor measure of quality.
The CMA and GAC each run popular
online CPG databases, with 20,000 and 80,000 hits a
month respectively, that can help narrow down a search
for a particular guideline. The CMA Infobase, operational
since 1994, warehouses 1,500 Canadian CPGs less than
five years old in over 40 areas of interest that have
been developed and endorsed by a Canadian organization.
Meanwhile, the GAC's newer, more user-friendly site
employs a scale from one (poor) to four (excellent)
and rates up to 500 guidelines from around the English-speaking
world.
Nevertheless, many busy physicians,
especially those like Dr Stewart, accustomed to referring
to a paper document, question how successful the internet
has been at increasing CPG consultation. "When I'm using
a guideline in the office, I need quick information...
[The internet] is still slower than grabbing a well-formatted
paper document that's sitting on my desk," he says.
Dr Lorne Marsh, a GP in Halifax,
agrees. "The problem for most of us is that it's time-consuming,"
he says. "Another thing is that the irony of the whole
thing is a lot of us don't have computers on every examination
desk loaded with the information that we require...."
Though the GAC's website is being
fine-tuned, Dr Dave Davis, the organization's chairperson,
echoes the sentiments of many in the guideline field
that implementation will be greatly improved when EHR
becomes standard. "If I have a patient's computerized
record in front of me and I see that she's hypertensive,
I click on the word 'hypertension', then click on 'guidelines'
and the summary pops up," he says of the theoretical
programs in the pipeline in some provinces.
Dr Stewart says the most important
thing is for provincial health ministries to work on
improving guideline implementation now. "You have to
[educate] each GP so that they know that the document
is valid, it's got to be formatted so that they can
use it and it has to be updated regularly. If one or
two critical steps are missing then the value of the
document is pretty much zero," he says.
Even if Dr Stewart's and Dr Davis's
hopes becomes reality, however, it doesn't necessarily
mean doctors will have the time, or the inclination,
to read CPGs. "Whatever medium is used, whether it be
computer or the printed medium, the fact that it's there
or the fact that it's visible doesn't mean we would
read it," says Dr Marsh. "Because it's going to be competing
with a lot of other important information."
For more information:
GAC: http://gacguidelines.ca/
CMA Infobase: http://mdm.ca/cpgsnew/cpgs/index.asp
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