Black N, Hutchings A
Health Services Research Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
Qual Saf Health Care. 2002 Jun;11(2):121-4. doi: 10.1136/qhc.11.2.121.
It is widely accepted that the passive dissemination of national clinical guidance has little or no impact on practice.
To assess the impact in England of an Effective Health Care bulletin on childhood surgery for glue ear issued in 1992 and to understand the reasons for any change (or lack of change) in practice that ensued.
Time series analysis of the rate of use of surgery by children under 10 years of age from 1975 to 1997/8 in 13 English health districts.
Following a rise in the rate of surgery in public (National Health Service) hospitals from 1975 to 1985, the rate declined by 1.6% a year from 1986 to 1992/3. Following publication of the guidelines in November 1992, the rate of decline increased to 10.1% a year. Even after allowing for a slight increase in the use of independent (private) hospitals between 1992/3 and 1997/8, the overall rate of decline was at least 7.9%. It appears that the rate of referral of cases by primary care physicians (general practitioners) halved during this period. Several contextual factors are thought to have contributed to the effect of the guidelines, including pre-existing professional concern about the value of surgery, the introduction of an internal market into the NHS, and growing apprehension among parents fuelled by scepticism in the mass media. During this unprecedented period of rapid change in usage, staff delivering the service remained unaware of the alterations in their own practice.
Passive dissemination of national guidelines can accelerate an existing trend in clinical practice if the context is hospitable. Policy makers should identify and target such situations.
人们普遍认为，国家临床指南的被动传播对实际医疗行为几乎没有影响。
评估1992年发布的一份关于儿童胶耳手术的《有效医疗保健》简报在英格兰产生的影响，并了解随之而来的实际医疗行为发生变化（或未发生变化）的原因。
对1975年至1997/8年期间英格兰13个卫生区10岁以下儿童的手术使用率进行时间序列分析。
1975年至1985年期间，公立（国民保健服务）医院的手术率上升，之后从1986年至1992/3年，手术率以每年1.6%的速度下降。1992年11月指南发布后，下降速度增至每年10.1%。即使考虑到1992/3年至1997/8年期间私立医院的使用略有增加，总体下降率至少为7.9%。在此期间，初级保健医生（全科医生）转诊的病例数似乎减半。一些背景因素被认为促成了指南的影响，包括专业人员此前对手术价值的担忧、国民保健服务体系引入内部市场，以及大众媒体的怀疑态度引发家长越来越多的担忧。在这一使用情况迅速变化的前所未有的时期，提供医疗服务的工作人员对自身医疗行为的变化仍浑然不觉。
如果环境适宜，国家指南的被动传播可加速临床实践中的现有趋势。政策制定者应识别并针对此类情况。
