Family Practice Vol. 20, No. 3, 350
© Oxford University Press 2003
Correspondence |
Coronary heart disease: acceptance of guideline recommendations irrelevant in Germany?
Abteilung Allgemeinmedizin, Universitätsklinikum Moorenstrasse 5 D-40225 Düsseldorf Germany
It is important to conduct research on how guidelines are accepted and implemented among GPs and to look for barriers to their implementation. We believe, however, that a comparison between countries must be made with great care; we know that there are differences in the organization of primary care between different European countries. We also know there are differences in the process of implementing guidelines between countries. However, only a few countries have a long tradition of producing and implementing guidelines, so only their GPs are used to them.
Any research, using any type of method, usually includes some sort of critical appraisal at the end. This includes a ‘comparison’ of the results with the reality—as perceived. In other words, when researchers have produced a result which contrasts greatly with reality, as they see it, they scrutinize their data and the methods used to obtain these results. This process of testing plausibility is hindered or even made impossible when conducting a telephone study, and is an even greater problem when doing research on other countries, i.e. making a medico-cultural comparison by telephone.
In the study by Hobbs and Erhardt,1 we felt that a number of findings regarding Germany were rather irritating. This is because they are in contrast to the reality which we perceive—starting with the number of consulting patients per month and ending with the central topic of that article, the use of guidelines. We would like to concentrate on the latter point only.
Contrary to the article’s suggestion, in Germany, there are no guidelines for general practice concerning coronary heart disease (CHD) or cholesterol. There are a few guidelines concerning CHD or cardiovascular risks produced by some specialist societies; these are without any co-operation with the German Society for Family Medicine. These guidelines do not have the national impact which the British national guidelines probably have; they are not distributed to general practices, and nobody really discusses them.
German GPs usually do not use European guidelines (because they usually do not know about them), be they for hypertension, cholesterol or CHD. As a slight exaggeration, one could say that German doctors would never use a guideline written in English. The only guideline which is translated but is not really distributed is the Jount European Societies’ Recommendations.
Furthermore, 95% of German GPs work in single-handed practices and a small proportion work with their spouses. The finding of the study that 66% of German doctors use their own guidelines therefore can only be a misunderstanding between interviewer and interviewee. German doctors probably meant that they have some sort of ‘internal guideline’, i.e. that they are acting according to some inner principle and not just by chance.
There is no health authority regulating the content of care, and there are no regional guidelines. What, at best, could be meant is that there are some rare ‘networks’ of doctors working on the improvement of care and partially using their own guidelines.
We do not recognize the German situation when reading this article. This is said on the basis of working as a German GP for several years (H-HA) and on doing research on German GPs’ attitudes towards guidelines (CO). We think that the results presented for Germany must have a very biased group of doctors in the background producing this distorted picture of reality.
Alternatively, the results could be the product of a misunderstanding via the telephone. We even dare to wonder about a third explanation: incorrect data provided by the marketing research agency employed to make the telephone calls.
The question that arises from such an article is: "which of the results for the other countries are nearer to reality?" It is a real problem of inter-cultural comparisons relying on only one method, in this case the telephone. Even a questionnaire as the only method can be a problem. The differences in culture, language, willingness to tell the truth and the context are too large to allow such simple methods to work.
Reference
1 Hobbs FDR, Erhardt L. Acceptance of guideline recommendations and perceived implementation of coronary heart disease prevention among primary care physicians in five European countries: the Reassessing European Attitudes about Cardiovascular Treatment (REACT) study. Fam Pract 2002; 19: 596–604.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||