EFFECTIVENESS OF CLINICAL GUIDELINES AS A MEANS FOR CHANGING BEHAVIOR

Introduction

Clinical guidelines are designed with the major aim of improving quality of health care. This is reflected in the utilisation of evidence based practices and the employment of a series of models. The paper shall look at some of the intended impacts of clinical guidelines as a method of changing behaviour and the actual impacts caused by them. Policy and procedural recommendations shall be given on any failure to meet the intended outcomes. (Grimshaw et al, 2001)

Definition of clinical guidelines and a brief description of the sources
Clinical guidelines may be defined as systematically developed statements that enable patients and practitioners to make decisions about their clinical circumstances and health care circumstances. Clinical guidelines are important in setting out the specific treatment and diagnostic modalities when dealing with patients. Additionally, these guidelines are important in setting out recommendations that have been drawn from published literature and systematic review. (Kanfer, F. & Saslow, 1999)

Usually, guidelines are important in doing the following;
• Defining practices that meet patient needs
• Describe general approaches for management, approaches and treatment of diseases and conditions

It should be noted that these guidelines are not fixed protocols as such, they are mere recommendations and responsible clinical management is what can ensure that patients receive the care that they deserve. In fact, each clinician ought to have his or her own kind of treatment plan that should be tailored to the needs of every patient and the specific circumstances under which these treatment plans are being carried out. (NICE, 2003a)

It should be noted that there are specific users that were targeted by this guidelines. The first category in this priority list is composed of clinicians. The latter term covers nurses, physicians, and health care professionals. Additionally, some non-clinicians such as managed care organisations or groups that deal with patients or health care resources as well are affected by these guidelines. It can therefore be said that the clinical guidelines supersede the clinical environment and reach other arenas that revolve around healthcare management. (Field & Lohr, 1992)


Clinical guidelines are usually written through expert panels. These panels may belong to different branches of medicine and are usually unpaid for their services. The latter committees are chaired by experts appointed by the health regulatory body on the basis of their expertise in clinical and scientific fields. After this expert panel has written down its draft, it is then reviewed by other external members who are also regarded as experts since they possess the same qualifications that the members of the committee do. The following features are usually examined after creation of these guidelines
• Practicality
• Clarity
• Formatting
• Usefulness of guidelines in practice(Grol et al, 1998)

After the external review has been done, then the expert panel looks into the comments given by the reviewers and makes changes on the draft that they have created. Thereafter, another draft is written down and posted on the NHS website so that the public can review it too. Usually, members are allowed to view their comments about it or they can attend a public forum convened by the expert panel that allows them to make comments about this second draft. (Eddy, 1990)

Given the common differences between these two groups, then there are certain circumstances in which a conflict of interest might arise between them. Normally, the review groups and members of the actual writing committee might have to manage conflicts of interests. In the event that such an issue occurs, then the members of the expert panel and the review team are expected to make a written statement about this to a review panel that operates internally. Matters surrounding their nomination and acceptance will be discussed in that particular statement.

While the most important factor in selection of members is both clinical and scientific expertise, the potential of conflict of interests is usually taken into consideration. Also, during a general meeting, members are supposed to reveal cases of conflict of interest through direct verbal disclosure. A methodologist may be hired to deal with writing groups to provide some sort of objectivity in the process of ranking evidence. Also this methodologist is given the responsibility is making evidence tables and facilitating consensus. Opportunities for public review are given the second time and a final decision is made. (Ley, 1988)

It should be noted that within the United Kingdom, there are close to 2000 guidelines that have been developed for auditing processes. In fact some clinicians have asserted that there may be too many tidal guidelines affecting their respective lives.

Expected impact of clinical guidelines in health care
One of the general expectations of clinical guidelines writers is improvement of health care quality. The latter are designed to provide recommendations that would assist in the care and treatment of patients by health care practitioners. The guidelines are supposed to be utilised both in the training and education of health professionals. This can go a long way in assisting patients to make the right kind of decisions. Additionally, communication between health professionals and patients should also be improved through these guidelines.

It is expected that these clinical guidelines will promote scientific quality during clinical practices. Additionally, they are intended on adding ethical dimensions in practise. This is largely because the guidelines seek to protect the rights of patients with regard to their clinical experience. (Kazdin, 2001)

Clinical guidelines are designed in order to assist in identification of major decisions to be made around patients. In this regard, care needs to be given to the potential repercussions of these choices. It should be noted that the process of dealing with patients is a very intricate one. Consequently, some sorts of guidelines can be very important in clarifying some of these issues. It should be noted that guidelines are important in determining some of the potential effects that clinical decisions can have on a patient. Most of the time, there are certain roadblocks that one may encounter when making decisions yet relatively little is know about the decision making process itself. (Baum Et al, 1997)


Some of the key decisions that doctors and other clinicians have to make include
• Weighing up consequences of treatment options
• Understanding outcomes of alternative treatments
• Knowing outcomes of risk and benefits of certain treatments
• Assessment of general outcome of treatment
• Estimating prognosis
• Making a diagnosis

Usually, one can be able to map out a diagram in order to understand key decisions that clinicians are confronted with and some of the effects of those decisions may have upon the patient (s) under consideration. (Eccles et al, 1996)

Clinical guidelines have also been created with the intention of putting together all the necessary and valid evidence that clinicians require in order to make informed decisions. It is assumed that the necessary research evidence is available in different fields of medicine. Additionally, emphasis is given to the key areas of decision making. Most of the time, there are certain kinds of problems that need solutions that are evidence based. A number of groups operating in these specific areas of research have acknowledged the fact that there should be adoption of comprehensive and systematic overviews of evidence by clinicians. (NICE, 2003b)

Evidence based practice is largely based on the existence of particular evidence related to specific patients. In this scenario, it is assumed that clinical guidelines will go a long way in assisting clinicians to make decisions about certain conditions because of the existence of evidence about a specific condition.

Research on the actual impact of clinical guidelines
Research shows that some of these intended outcomes are yet to be achieved. The first aspect that is with regard to making evidence based decisions. While the potential for existence of this kind of practice is high, much is yet to be done in terms of the practicality of these guidelines. Evidence based clinical guidelines are available in a format that may not be valuable to clinicians. For instance, one may find that the evidence in these clinical guidelines is presented in terms of relative rewards or relative risks. This means that in order for the latter guidelines to work, then clinicians need to be given information in absolute terms such as the number of health event that occurred in a certain year or the number of patients who require treatment in order to hinder occurrence of a certain event among other things. Since this kind of issue is missing for health practitioners, then it may be relatively difficult trying to come up with certain kinds of changes in this regard. (Eccles, 2001)

If clinical guidelines were presented in a manner that was directly useful to practitioners, then it would have been safe to say that the intended outcomes have been achieved. However, since this is not the case, then one can assert that the expected impacts of these programs have not yet been achieved. Perhaps, the likelihood of this occurrence can be heightened by updating clinical guidelines as more publications on evidence based practices have been unleashed. Explicit statements about the risks and rewards of certain patient treatments or issues can be weighed and the best decisions made. In fact, because of the lack of availability of evidence based publications, most guidelines are general in nature and hence lack the explicitness necessary for implementation of these outcomes.

Lastly, the intended impact of these clinical guidelines has been minimised by the kind of format that the guidelines are presented in. In order to ensure success of the guidelines, clinicians should be able to retrieve, access and understand information in these guidelines easily. Clinicians have moved with the times and because of the computer era, most of them have found that it is relatively easier to access their information through the World Wide Web. (Gollwitzer, 1999)


While the latter intervention may seem quite well intentioned, their implementations are yet to come to pass in this kind of arrangement. Most of the time, clinicians ted o look for guidelines that allow identification of key decisions and their consequences easily, a review of the relevant evidence required to review this information and lastly, there is a need to have information available in a simple but yet easily accessible format. (Grady et al, 1997)

However, there is a wide variation in health care practice that shows that practitioners are utilising different information to make their decisions. Such evidence is particularly embarrassing to the health care profession since clinical guidelines are supposed to be the common language that allows all health care stakeholders (such as scientists, purchasers, practitioners and patients) to share this information between one another. However, since this is not the case, then it can be said that there are still a number of things that need to be changed in this regard as health care variations are an embarrassment in the field. (Stern & Brennan, 1994)

Evidence based model
A number of researches have been done in evidence based models and their level of implantation. One such study was proven by Rashidian, A. And Russell I. In their study known as “Clinical guidelines in primary care – the complexities of changing prescribing behaviour in the NHS for the International Society of Technology Assessment in Health care in the year 2002. The main aim of this research was to assess the attitudes of general practitioners towards the major facilitators or barriers in implementation. The research was a qualitative study and utilised both semi structured and structured interviews.

The latter research used the some them sot identify what the overall issues were in terms of clinical guidelines and attitudes towards them. They were as follows
• Influencing people to implement
• Dissemination strategies
• Organisational factors
• Practitioner’s attitudes
• Guideline characteristics
• Disease characteristics

It was found that most clinicians had very little consensus on their respective guidelines. Additionally, it was also found that there was very little agreement on the kind of guidelines that were effective for certain conditions. On top of the latter, it was acknowledged that if the government backed up certain initiatives, then chances of success were much higher. Also, clinicians claimed that there was a positive influence of the guidelines on nurses but the same could not be said about computerisation of the guidelines and the use of primary care organisation in the implementation of these guidelines. (Cone,1997)

Diffusion of innovation, organisational theory and knowledge management
Application to policy or practise examples
It should also be noted that policies and practices can be utilised to change the overall impact of clinical guidelines as they are today. Usually, most policies have involved a series of complicated procedures such as educational outreach, reminders and feedback. However, evidence shows that certain simple policy procedures may go a long way in improving this kind of approach. (NICE, 2003 c)

One such route is the use of appropriate wording. Research shows that instead of placing too much emphasis on getting doctors to follow guidelines, perhaps policy procedures need to be changed so as to offer concise and clear recommendations. The first thing that could be done so as to ascertain that the statements used in these guidelines are concrete and statements made are easily understood.

If there are specific pan sin how behavioural changes can be made, then this can go a long way in ensuring that clinical guidelines affect changes. There are a wide series of evidence based practise incorporated in most clinical guidelines; however, much is yet to be done in terms of the explicitness of the instruction. A survey done among national clinicians nationwide revealed that sixty seven percent of the individuals who participated in this kind of review were able to implement the guideline because they were clear and precise. Conversely, only the thirty six percent of clinicians were able to change their behaviour when the policies and procedures were not clearly written down. (Eccles et al, 2001)

In this regard, it my be necessary for the clinical guidelines to specify the what, when, why and how of these issues critically. An example of how this needs to be done is through the use of National institute for clinical guidelines that were received by a wide number of NHS practitioners. The latter guideline was very rich in evidence based practice. However, there was an inadequacy in terms of behaviour specific issues. The guideline was very long and its recommendations were slightly over twenty pages. On the other hand, it is important to note that such specifications would have been highly effective if there are no other kinds of imperatives that these issues bring out. Also, the style in which this recommendation was made had a high effect on the kind of issues facing these particular issues. (Grol, 1997)

The process of specifying behaviour serves two major functions. The first is that it heightens the implementation process. As it has been asserted earlier, clear guidelines are more likely to increase clinician’s confidence of what needs to be done. Additionally, it can go a long way in ensuring that the antecedents and consequences of any clinical decisions are clearly understood thus improving behavioural outcomes. (NICE, 2002)

Conclusion
In order to change clinical behaviour, there are a series of complex issues that have to be covered. Clinical guidelines can contribute towards changing this behaviour but there is a disparity between the creation of these guidelines and their implementation. The most effective is to ensure that the guidelines are evidence based and that they reflect positively on this matter.

References

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The author of this article is a holder of Masters in Business Administration (MBA) from Harvard University and currently pursing PhD Program. He is also a professional academic writer. ResearchPapers247.Com>