Thomas L, Cullum N, McColl E, Rousseau N, Soutter J, Steen N
Centre for Health Services Research, University of Newcastle upon Tyne, 21 Claremont Place, Newcastle upon Tyne, Tyne and Wear, UK, NE2 4AA.
Cochrane Database Syst Rev. 2000(2):CD000349. doi: 10.1002/14651858.CD000349.
Clinical practice guidelines aim to reduce inappropriate variations in practice and to promote the delivery of evidence-based health care.
To identify and assess the effects of studies of the introduction of clinical practice guidelines in nursing (including health visiting), midwifery and other professions allied to medicine.
We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE (1975 to 1996), EMBASE, Cinahl and Sigle to 1996, the NHS Economic Evaluations Database (1994 to 1996), DHSS-Data (1983 to 1996), the Database of Abstracts of Reviews of Effectiveness (1994 to 1996) and reference lists of articles. We also hand searched the journal Quality in Health Care, made personal contact with content experts and contacted libraries identified by an expert panel.
Randomised trials, controlled before-and-after studies and interrupted time series analyses of the introduction of interventions comparing 1. Clinical guidelines plus dissemination and/or implementation strategies versus no guidelines; 2. Guidelines plus dissemination and/or implementation strategies versus guidelines plus alternative dissemination and/or implementation strategies; and 3. (post hoc) Guidelines used by professions allied to medicine versus standard physician care. The participants were nurses, midwives and other professions allied to medicine.
Two reviewers independently extracted data and assessed study quality.
Eighteen studies were included involving more than 467 health care professionals. The reporting of study methods was inadequate for all studies. In all but one study, nurses were the targeted professional group; one study was aimed solely at dieticians. The various behaviours targeted included the management of hypertension, low back pain and hyperlipidaemia. Nine studies were identified for comparison 1. Three out of five studies observed improvements in at least some processes of care and six out of eight studies observed improvements in outcomes of care. Only one study included a formal economic evaluation, with equivocal findings. Three studies were identified for comparison 2 but it was difficult to draw firm conclusions because of poor methods. Six studies were identified for comparison 3 (post hoc). These studies generally supported the hypothesis that there was no difference between care given by nurses using clinical guidelines and standard physician care.
REVIEWER'S CONCLUSIONS: There is some evidence that guideline-driven care is effective in changing the process and outcome of care provided by professions allied to medicine. However, caution is needed in generalising findings to other professions and settings.
临床实践指南旨在减少医疗实践中的不当差异，并促进循证医疗保健的提供。
确定并评估有关在护理（包括健康访视）、助产及其他医学相关专业中引入临床实践指南的研究的效果。
我们检索了Cochrane有效实践与医疗组织小组专门注册库、MEDLINE（1975年至1996年）、EMBASE、截至1996年的Cinahl和Sigle、NHS经济评估数据库（1994年至1996年）、DHSS数据（1983年至1996年）、有效性综述摘要数据库（1994年至1996年）以及文章的参考文献列表。我们还手工检索了《医疗保健质量》杂志，与内容专家进行了个人联系，并联系了专家小组确定的图书馆。
对干预措施引入情况进行的随机试验、前后对照研究和中断时间序列分析，比较：1. 临床指南加传播和/或实施策略与无指南；2. 指南加传播和/或实施策略与指南加替代传播和/或实施策略；3. （事后分析）医学相关专业使用的指南与标准医生护理。参与者为护士、助产士和其他医学相关专业人员。
两名评审员独立提取数据并评估研究质量。
纳入了18项研究，涉及467名以上医疗保健专业人员。所有研究的研究方法报告都不充分。除一项研究外，所有研究的目标专业群体均为护士；一项研究仅针对营养师。所针对的各种行为包括高血压、腰痛和高脂血症的管理。确定了9项用于比较1的研究。五项研究中有三项观察到至少某些护理过程有所改善，八项研究中有六项观察到护理结果有所改善。只有一项研究进行了正式的经济评估，结果不明确。确定了三项用于比较2的研究，但由于方法不佳，难以得出确切结论。确定了六项用于比较3（事后分析）的研究。这些研究总体上支持以下假设：使用临床指南的护士提供的护理与标准医生护理之间没有差异。
有一些证据表明，以指南为导向的护理在改变医学相关专业提供的护理过程和结果方面是有效的。然而，在将研究结果推广到其他专业和环境时需要谨慎。
