Harrison Stephen, Dowswell George, Wright John, Russell Ian
Department of Applied Social Science, University of Manchester, Manchester, UK.
J Health Serv Res Policy. 2003 Jul;8(3):149-53. doi: 10.1258/135581903322029494.
To explain recent rapid audited change in the uptake of locally implemented, evidence-based clinical guidelines for asthma and angina in primary care.
A case study of primary care in two matched, adjacent districts in Northern England, focusing on a stratified random sample of 49 general practitioners (GPs) from eight primary care groups. Data were collected from three cycles of mainly qualitative interviews carried out at six-monthly intervals, before and after the dissemination of local guidelines and after audit data were gathered. Interviews examined attitudes, awareness and impact of locally disseminated asthma and angina guidelines and the subsequent audit. Audit data on guideline uptake were also available from a parallel study.
The rapid increase in guideline uptake observed in both intervention and control groups was not explained by individual practitioners or practice factors. The findings are attributed to GPs' awareness of policies for evidence-based medicine, of new health service institutions and of the clinical governance activities of primary care groups. Behaviour change reflects GPs' decisions about what to record in case notes as well as their clinical decisions, so that findings may reflect changing perceptions about accountability rather than about preferred treatment regimes.
Guideline production and dissemination is best seen in the broader context of policy change. Studies of guideline implementation should report before and after data and incorporate significant qualitative components in order to identify important contextual factors.
解释近期在基层医疗中，针对哮喘和心绞痛的本地实施的循证临床指南的采用情况出现的快速经审核的变化。
对英格兰北部两个匹配的相邻地区的基层医疗进行案例研究，重点关注来自八个基层医疗组的49名全科医生（GP）的分层随机样本。在本地指南发布之前和之后以及收集审核数据之后，每隔六个月进行三轮主要为定性访谈，收集数据。访谈考察了本地发布的哮喘和心绞痛指南以及随后审核的态度、认知和影响。关于指南采用情况的审核数据也可从一项平行研究中获得。
在干预组和对照组中观察到的指南采用率的快速上升，无法用个体从业者或医疗机构因素来解释。研究结果归因于全科医生对循证医学政策、新的卫生服务机构以及基层医疗组临床治理活动的认知。行为变化反映了全科医生关于在病历中记录内容的决定以及他们的临床决策，因此研究结果可能反映了对问责制的认知变化，而非对首选治疗方案的认知变化。
在政策变化的更广泛背景下看待指南的制定和传播最为恰当。指南实施研究应报告数据前后情况，并纳入重要的定性内容，以便识别重要的背景因素。
