Family Practice Vol. 19, No. 3, 223-230
© Oxford University Press 2002
Original Paper |
The effectiveness of local adaptation of nationally produced clinical practice guidelines
a Monash Institute of Health Services Research, Monash Medical Centre, Clayton, Victoria 3168, Australia,
b Department of General Practice, University of Edinburgh, West Richmond Street, Edinburgh, UK,
c School of Health Services Management, University of New South Wales,
d Australasian Cochrane Centre, Flinders Medical Centre, Adelaide 5001 and
e Department of General Practice, Flinders University, Adelaide 5001, Australia.
DP Weller, Department of General Practice, University of Edinburgh, West Richmond Street, Edinburgh, UK.
Silagy CA, Weller DP, Lapsley H, Middleton P, Shelby-James T and Fazekas B. The effectiveness of local adaptation of nationally produced clinical practice guidelines. Family Practice 2002; 19: 223–230.
Received 1 May 2001; Revised 6 September 2001; Accepted 7 January 2002.
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Abstract |
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Background. Local adaptation is often reported in the literature to be an important strategy in achieving local ownership and relevance of guidelines in order to increase the likelihood of their uptake and implementation. However, the process is also potentially time-consuming and costly.
Objective. The aim of this study was to determine the impact of local adaptation of nationally produced clinical practice guidelines (CPGs) on the knowledge, attitude and reported practices of GPs.
Methods. Two Divisions of General Practice in Adelaide, Australia were selected and randomized to adapt a nationally produced CPG (on Stroke Prevention) by the National Health and Medical Research Council or use the original version. The order of the interventions was reversed for a second guideline (on management of Lower Urinary Tract Symptoms in Men). An identical multifaceted dissemination strategy was adopted for both sets of guidelines in the two divisions. Prior to the intervention, a random sample of 200 GPs from each Division was sent a postal survey about their knowledge, attitudes and reported practices. This was repeated 3 months after the dissemination phase.
Results. Sixty-one per cent (243/400) of the GPs responded to the initial survey and, of these, 76% (184/243) responded to the follow-up survey. Overall, awareness of both sets of guidelines was significantly increased. For stroke, 38% of respondents across both Divisions reported that their practice had changed as a result of the guidelines. For management of lower urinary tract symptoms in men, the corresponding proportion was 52%. Agreement with specific recommendations from both guidelines was also increased following their dissemination. However, these changes were independent of whether or not the guidelines had been locally adapted. The local adaptation process involved no substantive change in content and was estimated to cost AUD$5600 (per Division) independent of the costs of the dissemination process.
Conclusions. Whilst this study found significant changes in knowledge, attitude and reported practice as a result of disseminating guidelines, it did not find any additional effect from the local adaptation process itself. This suggests that the emphasis and investment in promoting guideline implementation should be placed on multifaceted dissemination strategies rather than local adaptation per se.
Keywords. General practice, guidelines, local adaptation, lower urinary tract symptoms, stroke.
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Introduction |
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The last decade has seen a proliferation of evidence-based clinical practice guidelines throughout the world. Frequently these have been generated nationally, with little or no involvement of local end-users, such as GPs, and then disseminated through the mail or published in journals.1 More recently, there has been increasing attention paid to the involvement of end-users in both the development and implementation process. Whilst there is some evidence that involvement of end-users in the guideline development process may lead to increased uptake of the guidelines,2 there are also counter concerns that local guidelines may be perceived as less credible than those produced by recognized national bodies. Furthermore, even though end-user involvement may improve adoption, it entails much duplication of effort and could result in a negative impact on the motivation levels of those involved (as well as increased time, costs and poorer quality guidelines).3
An alternative approach, which relies on local adaptation of guidelines developed at the national level by expert groups, has been trialed overseas with some reported success but little formal evaluation. Development of evidence-based guidelines at the national level by a multidisciplinary group, with adaptation to the local context by local practitioners, is an approach which has been used in Scotland as part of the Scottish Intercollegiate Guideline Network (SIGN).4 Advocates of this approach have argued that sound systematic evidence-based approaches can be employed at the national level (particularly since the skills required for this are unlikely to be available in every local context); duplication of effort is avoided; and yet clinical practice guidelines can still be responsive to local contexts in a cost-effective manner.5
Similar arguments have been proposed for a multilevel development approach, with centrally developed guidelines that are evidence-based, which can then be modified as necessary at the local level to take account of specific contextual issues.6,7
However, large-scale local adaptation is a potentially costly process that also requires adequate local skilled personnel to support it. In Australia, where up to 125 separate adaptations of any guideline might be necessary (assuming geographical groupings such as Australia's Divisions of General Practice are used as the basis of local adaptation), it is important to have clear evidence of any benefit that results from the local adaptation process.
This study was designed, therefore, to distinguish between the local adaptation process and the subsequent dissemination and implementation of guidelines. The primary objective was to assess the effectiveness of the local adaptation process on the uptake of nationally produced evidence-based clinical practice guidelines. A secondary objective was to identify the economic costs associated with this process.
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Methods |
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Study design
Two Divisions of General Practice in metropolitan Adelaide were selected to participate in the study. Each consists of ~120 separate practices together with several smaller secondary care hospitals and a major tertiary teaching hospital. Two nationally produced clinical practice guidelines commissioned and released by the Australian National Health and Medical Research Council were selected (Prevention of Stroke8 and The Management of Lower Urinary Tract Symptoms in Men9). They were chosen because the content was relevant to general practice and addressed areas where there was evidence that there was variation in practice between different GPs.10
Based on a coin toss, one Division (A) was allocated to adapt the Prevention of Stroke Guidelines locally. The other Division (B) was therefore allocated to adapt the Management of Lower Urinary Tract Symptoms in Men Guidelines locally. In each Division, the set of guidelines that were not being locally adapted were still disseminated, but unchanged from the nationally produced version. GPs in each division would thus be sent two sets of guidelines, the nationally produced version of one, and the locally adapted version of the other.
Local adaptation of the guidelines
The process of local adaptation followed the methodology developed by Woolf11 and included a formal assessment of scientific evidence in the national guidelines, panel meetings and open forum sessions that sought broad input on relevant analytical issues.
Local adaptation of the guidelines focused on a number of issues. The prevalence of the condition in the local region, local community priorities (where known and relevant), availability of resources, services and technologies, access to consumer information and support, and any special organizational relationships existing between health care providers and agencies within the region were all considered.
The panel meetings provided an opportunity for expert opinion input. The panel was multidisciplinary, including local GPs, relevant specialists, an epidemiologist with expertise in guideline development, allied health professionals and consumer representatives.
Three months was allocated for the local adaptation process, which occurred simultaneously in the two Divisions. The process was assisted by a single facilitator to ensure consistency between the two Divisions.
The end result (in both Divisions) was a locally adapted guideline that was almost identical in content to the national version. The main differences related to the inclusion of additional information regarding availability of local resources and a more ‘user friendly’ formatting.
Dissemination and implementation of the guidelines
The guidelines were disseminated and implemented using identical methods in both Divisions and for both sets of guidelines, irrespective of whether they had been locally adapted or nationally produced.
The standardized dissemination method involved:
- Mailing all doctors (both GPs and specialists) in the region a copy of the guidelines (either in the national or locally adapted format). Doctors received the GP version of the two nationally produced clinical practice guidelines but were able to request copies of the more comprehensive versions of the two documents.
- Production of one article for each of the regular monthly newsletters of the Divisions of General Practice explaining the guidelines.
- Provision of all GPs with a prompt sheet that included reminders to the key elements of the guidelines, and was designed to be used during a consultation.
- An invitation to all doctors in the region to attend one evening Continuing Medical Education (CME) workshop to explain the guidelines. A local specialist who was an expert in the content area conducted all the workshops; their presentation was based around the material contained in the guidelines.
- Links to the guidelines through the relevant Divisions of General Practice web pages.
Outcome assessment
In order to assess the impact of the guideline development and implementation process, a random sample of 200 GPs was selected from each of the two Divisions using a current membership list.
The GPs selected initially were sent a questionnaire 3 months prior to the local adaptation process designed to assess their knowledge, attitudes and (self-reported) current practice about the management of the two target conditions (lower urinary tract symptoms in men, and prevention of stroke). Questions were developed using the highly structured format of the nationally produced guidelines that contained specific statements about what constituted effective practice. In addition, the questionnaire collected basic socio-demographic characteristics and information about the attitudes of doctors towards clinical practice guidelines in general.
The questionnaire was mailed out to doctors with a letter of introduction signed by both the Chief Investigator and the Medical Director of the Division briefly explaining the project. A self-addressed stamped envelope was included for the return of the questionnaires. They were provided with an incentive to return the questionnaire within a 2-week period by an offer of two free cinema tickets.
After 2 weeks, non-respondents were sent a further questionnaire with a reminder letter. After a further 2 weeks, non-respondents were telephoned to check receipt of the questionnaire and to encourage completion.
A follow-up questionnaire was sent to those people who responded to the baseline survey 3 months after the local adaptation and dissemination of the guidelines. The follow-up survey was very similar in structure and content to the baseline version. The knowledge questions were identical to the baseline questionnaire. However, there were also several additional questions designed to assess their knowledge of the existence of the two guidelines, their perceptions about whether the guidelines had made any impact on their clinical practice, and which of the dissemination strategies they felt had been effective.
Data analysis
The data set used for analysis included all respondents to the baseline survey. For comparisons between the baseline and follow-up survey, an ‘intention-to-treat’ approach was used in which all non-respondents to the follow-up survey were regarded as having not changed their knowledge, attitudes or practices from what they reported at baseline.
Descriptive statistics were used to analyse the data collected in the baseline and follow-up surveys, most of which contained categorical or ordinal responses. For differences in proportions between the two Divisions, we used Newcombe's test to calculate confidence intervals around the difference in unpaired proportions. For within-Division changes in knowledge, attitude and reported practice between the first and second survey, we used Newcombe's test for differences in paired proportions.
Software from the Confidence Interval Analysis program was used to perform the calculations.12
Economic analysis
A formal cost–benefit analysis by translating the outcomes of the adaptation and dissemination process into monetary values was not undertaken. Rather, we identified the economic costs in the study and used these to estimate study expenditures on adaptation, dissemination and evaluation. From this, we calculated the total expenditure required for a Division of General Practice to adapt a nationally produced guideline locally.
All expenditure identified in the accounts held by Flinders University for the study was allocated to one of three expenditure categories: adaptation, dissemination or evaluation. This allocation was achieved through a variety of means including consideration of original supporting documentation (e.g. receipts) and clarification with study staff involved with the project. We also considered the nature of the expenditure (e.g. overhead).
Expenditure not brought to account was quantified and included in total expenditure including sponsorship and donation of resources in relation to CME evenings and meetings associated with the local adaptation process.
The total allocated expenditure (adaptation and dissemination) for the period was then adjusted to reflect the expenditure per guideline across each of the two general practice Divisions or for individual GPs. Average expenditure levels are reported in all instances. No attempt was made to perform a marginal analysis.
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Results |
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Characteristics of respondents
The overall response rate to the initial survey was 61% (n = 243). Of these, 76% (n = 184) responded to the follow-up survey (Fig. 1
). There were no significant differences in response rates or baseline characteristics of respondents between the two Divisions (Table 1).
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Overall, a higher proportion (64%, n = 155) of respondents to the baseline survey were aware of the Stroke Prevention Guidelines at baseline than those who were aware of the Lower Urinary Tract Symptom Guidelines (38%, n = 93). There were no significant differences in the proportion of doctors between the two Divisions who were aware of the existence of the national guidelines at baseline.
Guideline uptake
Although the respondents (and non-respondents) to the baseline survey were sent copies of the guidelines, only 74% (n = 137) of those responding to the follow-up survey reported receiving the Lower Urinary Tract Symptom Guidelines and 80% (n = 148) the Stroke Prevention Guidelines respectively (Table 2). There were no significant differences between the two Divisions in the proportions reporting that they had received the guidelines.
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A much smaller proportion reported that the guidelines had led to a change in their practice (51%, n = 95 and 38%, n = 70 for the Lower Urinary Tract Symptom and Stroke Prevention Guidelines, respectively).
Knowledge and reported practice in relation to specific guideline recommendations
Comparisons were made between the recommendations contained within the guidelines and the self-reported knowledge and practices of respondents to the two surveys (see Table 3).
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When the changes in the two Divisions were compared to determine what effect local adaptation may have contributed, the only significant differences were a greater increase in Division A (where the guidelines had been locally adapted) in the proportion of GPs whose knowledge or practice became more consistent with the guidelines about (i) the appropriate use of aspirin in stroke prevention and (ii) the initial investigations for a patient with carotid stenosis.
The only significant differences between the two Divisions in relation to compliance with the Lower Urinary Tract Symptom Guidelines related to the use of finasteride and the criteria for considering surgery. In both cases, compliance with guidelines increased in both Divisions; however, the increase was significantly greater in Division A for appropriate use of finasteride and in Division B (where the guidelines had been locally adapted) for reported compliance with the criteria for considering surgery. It is notable that in the second of these examples, the locally adapted guidelines did not differ from the corresponding national guideline recommendations.
Economic analysis
1) Study expenditures..
The total expenditures identified during the study are presented in summary at Table 4.
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The adaptation expenditure per guideline per GP Division was estimated at $11 274. This figure was derived from the total expenditure allocated to this function in the study. Two adaptation processes were undertaken, one in Division A and one in Division B. The dissemination expenditure per guideline per GP Division was estimated at $6761. This figure was derived from the total expenditure allocated to this function in the study. However, unlike the adaptation process, the dissemination strategy was applied to both guidelines for each GP Division. In effect, four dissemination processes were undertaken.
Salaries and wages accounted for >70% of costs brought to account, while publication expenses (10%) represented the largest expenditure item in relation to Goods and Services. A number of expenditure items were not brought to account in the Flinders University financial records. For example, expenditure for CME and local adaptation meetings was estimated independently from supporting documentation and sponsor records.
2) Fixed and variable costs.. While it was difficult to determine with sufficient precision the nature and allocation of expenditure across functions, we are able to comment on the variable and fixed nature of the expenditure.
For the purpose of this study, salaries and wages and other expenditures have been taken to be fixed, whereas goods and services expenditure have been taken to be variable given the nature of the predominant expenditure items in each.
The expenditures on the adaptation process were largely (94%) taken up with fixed labour costs including medical practitioners' time and academic and project staff, whereas labour costs only accounted for 38% of the expenditure on the dissemination processes.
Goods and services costs including printing and the costs of documents accounted for 44% of total expenditure. These costs are more variable in nature, being largely dependent on the number of GPs involved.
A summary of the variable and fixed components of the expenditure in the study is presented in Table 5.
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Discussion |
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Overall, the results suggest that involvement of end-users in a process of locally adapting clinical practice guidelines may not in itself be an essential prerequisite to ensuring changes in knowledge or practice. However, the study has demonstrated that a multifaceted dissemination process at the local level was generally effective in achieving a small increase in the reported consistency of GPs' knowledge and self-reported practice with clinical practice guideline recommendations.
At first sight, this may be at odds with earlier suggestions that local involvement of end-users in guideline development is essential to their subsequent successful uptake.13 Guideline development is a complex process involving formal and rigorous assessment of evidence through processes such as systematic review and critical appraisal of literature.14 Special skills are required for such tasks, and the resources needed to support this are unlikely to be available at the local level. Organizations such as the National Health and Medical Research Council, who accept responsibility for developing clinical practice guidelines at a national level are ideally positioned to access such resources and to support those involved in their development.
In this study, both Divisions of General Practice used a similar process to adapt guidelines locally, but the end results were guidelines that were not substantially different from those developed nationally. This may be due to a general agreement with the original evidence base and its assessment (and possibly a reluctance and lack of resources to challenge this substantially). Even though a research assistant was made available to the local adaptation groups, only minimal additional literature searching was undertaken, and this was largely to confirm that new evidence had not become available since the publication of the respective sets of national guidelines. The formatting of the locally adapted version of the guidelines also retained many similarities to the original documents. This probably reflects the considerable effort that had gone in previously at a national level to producing user-friendly documents. Given the similarities between the national and locally adapted versions of the guidelines, it is not surprising that there was no significant difference found between the effect of the guidelines in the two Divisions. The need for a local adaptation process may be different in those situations where there is a likelihood of more profound differences between the adapted and non-adapted versions of the guidelines. It may be possible to make a priori judgements about the likelihood of this occurring.
In contrast (with a few exceptions), the changes in reported knowledge and practice following the dissemination process within each of the Divisions are also not surprising. Our project utilized a multifaceted dissemination and implementation strategy with a number of prongs based on existing research about effective behavioural change intervention.15 This approach incorporated use of local opinion leaders in the presentation of guidelines and substantial use of local dissemination resources that create an atmosphere of local ownership and relevance of the guidelines. It is possible that the key determinant of local input is the use of local people in the dissemination process rather than in a local adaptation process per se. This confusion between local involvement in the two different processes may have led to confounding in previous studies which have examined this issue where there has not been an attempt to ‘control’ for the dissemination process.
A limitation of the present study is that it may be under-powered to detect an effect of local adaptation. The unit of allocation for the study was the Division of General Practice. The study only had two Divisions involved and, despite the use of randomization, we almost certainly have not been able to control for all potential confounding variables. Ideally, we would have liked to undertake a much larger study, randomly allocating many more Divisions; however, the cost of doing this was prohibitive and lack of funding precluded us from proceeding with such an option.
A further limitation of the present study was the reliance on changes in knowledge and self-reported practice rather than changes in actual practice. Initially, we had endeavoured to address this by collecting information on PSA screening rates and auditing the use of measures for secondary prevention of stroke from patient records. However, logistic difficulties relating to the lack of computerized medical record systems, no patient registers and a complicated mix of private and public laboratory testing prevented us from obtaining such information. With the move towards computerization of medical records in Australia and growing linkage of records between different public and private providers, it should be possible to collect such outcome data in association with implementation research projects of this kind in the future.
Finally, the economic analysis undertaken as part of this study has identified that there are considerable fixed costs associated with a local adaptation process, that would be magnified considerably if local adaptation was undertaken for every guideline produced in Australia. Based on the costs identified in this study ($11 274 to adapt one guideline per Division), this would translate into a total cost for local adaptation of $1.4 million per guideline across the 125 Divisions in Australia. Given the apparent lack of effectiveness of the adaptation process, it would suggest that there is considerable potential for wasting resources if local adaptation was extended nationwide for every set of new guidelines. In contrast, it is possible that with the effectiveness and relatively low expenditure associated with use of locally based dissemination strategies, focusing on this may be a more appropriate use of limited resources.
In conclusion, until a larger study randomizing multiple Divisions of General Practice suggests otherwise, in order to achieve significant change in knowledge and self-reported practice consistent with clinical practice guidelines, the emphasis at the local level should probably be placed on use of multifaceted dissemination strategies rather than local adaptation. An exception to this might be those situations where there is an a priori reason to believe that local adaptation is likely to result in significant changes to nationally produced guidelines.
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Acknowledgments |
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We thank the GPs in both Divisions who participated in the study; Mr Ian Brown (who undertook the economic analysis); Drs Tracey Cheffins and Peter del Fante (Medical Directors of the Divisions involved in the study); and Ms Julie Halbert (who provided extremely helpful advice to the study management group). The study was supported by a grant from the Commonwealth Department of Health and Aged Care (General Practice Evaluation Program).
Chris Silagy died in December 2001. He will be sadly missed by his fellow authors of this paper.
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Notes |
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Deceased. 
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References |
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1 Gupta L, Ward J, Hayward RSA. Clinical practice guidelines in general practice: a national survey of recall, impact and outcome. Med J Aust 1997; 166:69–72.[Web of Science][Medline]
2
Grimshaw JM, Hutchinson A. Clinical practice guidelines—do they enhance value for money in health care. Br Med Bull 1995; 51:927–940.
3
Onion CWR, Walley T. Clinical guidelines: development, implementation and effectiveness. Postgrad Med J 1995; 71:3–9.
4 Petrie JC, Grimshaw JM, Bryson A. The Scottish Intercollegiate Guidelines Network Initiative: SIGN—getting validated guidelines into local practice. Health Bull (Edin) 1995; 53:345–348.
5 Grimshaw J, Eccles M, Russell I. Developing clinically valid practice guidelines. J Eval Clin Pract 1995; 1:37–48.[Medline]
6 Grol R. Standard of care of standard care? Guidelines in general practice. Scand J Primary Health Care 1993; 11 (Suppl):26–31.[Medline]
7 Wise B. A model of practice guideline adaption and implementation: empowerment of the physician. Joint Community J Qual Improv 1995; 21:456–476.
8 National Health and Medical Research Council (NHMRC). Clinical Practice Guidelines: Prevention of Stroke. The Role of Anticoagulants, Antiplatelet agents and Carotid Endarterectomy. Canberra: Australian Government Publishing Service, 1997.
9 National Health and Medical Research Council (NHMRC). Clinical Practice Guidelines: Management of Lower Urinary Tract Symptoms in Men. Canberra: Australian Government Publishing Service, 1997.
10 Pinnock C, Weller D, Marshall V. Self-reported prevalence of prostate-specific antigen testing in South Australia: a community study. Med J Aust 1998; 169:25–28.[Web of Science][Medline]
11
Woolf SH. Practice guidelines, a new reality in medicine. II Methods of developing guidelines. Arch Intern Med 1992; 152:946–952.
12 Altman DG, Machin D, Bryant TN, Gardner MJ. Statistics with confidence. Confidence Interval Analysis Software. Statistics in Medicine, 2nd edn. London: BMJ Publishing, 2000.
13 Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342:1317–1322.[Web of Science][Medline]
14 National Health and Medical Research Council (NHMRC). A Guide to the Development, Implementation and Evaluation of Clinical Practice Guidelines. Canberra: Australian Government Publishing Service, 1998.
15
Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thomson MA. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. The Cochrane Effective Practice and Organization of Care Review Group. BMJ 1998; 317:465–468.
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