Allen Hutchinson

Potential benefits, limitations, and harms of clinical guidelines

This is the first in a series of four articles on issues in the development and use of clinical guidelines Over the past decade, clinical guidelines have increasingly become a familiar part of clinical practice. Every day, clinical decisions at the bedside, rules of operation at hospitals and clinics, and health spending by governments and insurers are being influenced by guidelines. As defined by the Institute of Medicine, clinical guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”1 They may offer concise instructions on which diagnostic or screening tests to order, how to provide medical or surgical services, how long patients should stay in hospital, or other details of clinical practice The broad interest in clinical guidelines that is stretching across Europe, North America, Australia, New Zealand, and Africa (box) has its origin in issues that most healthcare systems face: rising healthcare costs, fueled by increased demand for care, more expensive technologies, and an ageing population; variations in service delivery among providers, hospitals, and geographical regions and the presumption that at least some of this variation stems from inappropriate care, either overuse or underuse of services; and the intrinsic desire of healthcare professionals to offer, and of patients to receive, the best care possible. Clinicians, policy makers, and payers see guidelines as a tool for making care more consistent and efficient and for closing the gap between what clinicians do and what scientific evidence supports. As guidelines diffuse into medicine, there are important lessons to learn from the firsthand experience of those who develop, evaluate, and use them.3 This article, the first of a four part series to reflect on these lessons, examines the potential benefits, limitations, and harms of clinical guidelines. Future articles will review lessons learned …

The Diabetes Health Profile (DHP): a new instrument for assessing the psychosocial profile of insulin requiring patients--development and psychometric evaluation.

The aim of the studies was to evaluate the psychometric properties and construct validity of the Diabetes Health Profile (DHP-1). Content for the DHP-1 was derived following in-depth interviews with 25 insulin dependent and insulin requiring patients, a review of the literature and discussions with health care professionals. Initial analysis of the factor structure of the DHP-1 was carried out on the responses of 239 insulin dependent and insulin requiring patients, with a mean age of 40.85 years (SD=13.0), resulting in a 43 item three factor solution. The 43 item version of the DHP-1 was completed by 2,239 insulin dependent/requiring patients (mean age = 39.8, SD=10) years. Fifty-one per cent were men. A forced three factor Principal Factoring Analysis with varimax rotation was carried out. Eleven items were excluded with item factor cross loadings >0.30 or item factor loadings <0.30. PAF analysis of the 32 items resulted in a three factor solution accounting for 33% of the total explained variance. The three factors were interpreted as Psychological Distress, Barriers to Activity and Disnhibited Eating. Factor congruence between subsamples were: Psychological distress (0.93), Barriers to Activity (0.93) and Disinhibited Eating (0.99). Coefficients of congruence between men and women were 0.94, 0.92 and 0.99 for Psychological Distress, Barriers to Activity and Disinhibited Eating respectively. Internal consistency of the three factors (Cronbachs α) were: Psychological Distress (0.86), Barriers to Activity (0.82), and Disinhibited Eating (0.77). Construct-convergent validity was investigated on a sample of 233 insulin dependent and insulin requiring patients (mean age = 51.46 years). Psychological Distress and Barriers to Activity subscales correlated with the Hospital Depression and Anxiety Scale = 0.50 to 0.62, p<0.01 and subscales of the SF-36 (range: r=−0.17 to -0.62, p<0.01). These findings lend support to the construct validity and reliability of the DHP-1 and that it is suitable for further development.

Development of a symptom based outcome measure for asthma.

Measuring symptom specific health outcome is complex, but the methodologies now exist to develop measures with the appropriate properties. As one element of a major programme to develop multidomain health outcome measures for chronic disease, a symptom based measure for asthma care has been developed for use in general practice and outpatient departments. This article outlines the development process, which used a framework recently described in the theoretical literature to show the constraints that scientific criteria place on the development of outcome measures and the means of overcoming such limiting factors. Although substantial effort is required to undertake a rigorous process of development, useful tools are the result. Two five item, symptom based outcome measures for adult asthma are described.

Primary care teamwork-making it a reality

Although Primary Health Care Teams have been part of the NHS for twenty years, not all teams have developed a satisfactory level of professional collaboration. Review of the research shows that interprofessional collaboration is not to be taken for granted and that there are many influences which adversely affect teamwork.A recent small survey of teams in Northumberland mirrored the national picture. Findings included accommodation problems, professionals with a considerable number of colleagues with whom to relate and there was clear evidence of difficulty in understanding the role of others. On the other hand, records were being shared and many respondents did feel part of a functioning team.The Northumberland Primary Care Forum used the results of the survey to stimulate debate among professionals and managers. Members of all 51 teams were provided with a workbook which identified some of the major constraints on teamwork, and offered suggestions for resolution. This work has formed the basis for a rea...

Conjuntos Mínimos de Datos en La Atención Ambulatoria

Resumen La demanda creciente de informacion en un sector caracterizado a nivel europeo por su gran complejidad y variabilidad como es el de la atencion ambulatoria, aconseja un planteamiento prudente de la metodologia a emplear en las iniciativas que pretendan avanzar en la armonizacion de conjuntos de datos. El presente trabajo resume una parte de la elaboracion conceptual del proyecto Measurement, Characterization and Control of Ambulatory Care in Europe (McACE) patrocinado por la Comision de las Comunidades Europeas dentro de la fase exploratoria del programa Advanced Informatics in Medicine (AIM). Nuestro planteamiento coloca en un primer plano la eficiencia a la hora de valorar las necesidades de los diferentes actores intentando evitar la descompensacion entre los gastos que representa la recogida y procesamiento de un determinado item y su utilidad. Para ello se ha realizado una validacion conceptual del termino «Conjunto Minimo de Datos Basicos» y su posible aplicacion al campo ambulatorio. Se propone su sustitucion por el de «Conjuntos Minimos de Datos» como herramienta practica para promover la armonizacion de la informacion en atencion ambulatoria.

Minimum Data Sets for Ambulatory Care

A sensible and rational approach is necessary in order to match the growing requirements of information on the ambulatory care sector characterised by a big deal of complexity and variability. This must be applied to any initiative attempting to obtain any degree of harmonization in ambulatory care data sets. This paper summarises a conceptual aspect of the work undertaken by the project Measurement Characterization and Control of Ambulatory Care in Europe (McACE) sponsored by the Commission of the European Communities under the exploratory phase of the Advanced Informatics in Medicine (AIM) programme. Our approach places in the first priority the efficiency when assessing the information needs of the different actors trying to make a balanced approach between the costs of collecting and processing a specific item and its use. For this we performed a conceptual validation of the term Minimum Basic Data Set and its potential application to the Ambulatory Care Sector. It is suggested its substitution by the term Minimum Data Set as a part of a practical tool for promoting the harmonization of the information in ambulatory care.

Collaboration between doctors: A study of referral decision making

The referral of patients to hospital specialists by general practitioners is a social process involving a series of interactions within and between the primary and secondary sectors of health care. Whilst a range of factors influencing referral decisions have been identified in previous studies, the main focus of this paper is the role of social relationships. Data from thirty interviews with general practitioners is used to show that relationships between doctors (partners and consultants) have a bearing on whether and/or when a patient is referred and to whom. We argued that the major significance of relationships for decision-making is that they are sources of information and thus influence the interpretation of clinical and non-clinical symptoms. We suggest that the concept of social network can usefully describe the informal organisation of relationships between clinicians.