Silagy C A, Weller D P, Lapsley H, Middleton P, Shelby-James T, Fazekas B
Monash Institute of Health Services Research, Monash Medical Centre, Clayton, Victoria 3168, Australia.
Fam Pract. 2002 Jun;19(3):223-30. doi: 10.1093/fampra/19.3.223.
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.
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.
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.
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.
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.
文献中经常报道，为了提高指南的采用率和实施可能性，使指南具有地方特色并与当地实际情况相关联，地方适应性调整是一项重要策略。然而，这一过程也可能既耗时又成本高昂。
本研究旨在确定对国家制定的临床实践指南（CPG）进行地方适应性调整对全科医生的知识、态度和报告的实践行为的影响。
选取澳大利亚阿德莱德的两个全科医学部门，并将其随机分组，一组对国家卫生与医学研究委员会制定的国家CPG（关于中风预防）进行适应性调整，另一组使用原始版本。对于第二项指南（关于男性下尿路症状的管理），两组干预的顺序相反。在这两个部门中，针对这两套指南均采用了相同的多方面传播策略。在干预之前，从每个部门随机抽取200名全科医生，通过邮寄方式对他们的知识、态度和报告的实践行为进行调查。在传播阶段结束3个月后，再次进行此项调查。
61%（243/400）的全科医生回复了初始调查，其中76%（184/243）回复了后续调查。总体而言，两组指南的知晓率均显著提高。对于中风指南，两个部门中38%的受访者表示，由于该指南，他们的实践行为发生了改变。对于男性下尿路症状的管理指南，相应比例为52%。在指南传播之后，对两套指南具体建议的认同度也有所提高。然而，这些变化与指南是否进行了地方适应性调整无关。地方适应性调整过程并未涉及内容上的实质性改变，估计每个部门的成本为5600澳元，这还不包括传播过程的成本。
虽然本研究发现，传播指南使知识、态度和报告的实践行为发生了显著变化，但未发现地方适应性调整过程本身有任何额外效果。这表明，促进指南实施的重点和投入应放在多方面传播策略上，而非地方适应性调整本身。
