Centre for Kidney Research, The Children's Hospital at Westmead, NSW, Australia 2145.
Am J Kidney Dis. 2010 Feb;55(2):241-9. doi: 10.1053/j.ajkd.2009.09.032. Epub 2010 Jan 4.
A consistent gap exists between evidence-based guideline recommendations and clinical practice across all medical disciplines, including nephrology. This study aims to explore nephrologists' perspectives on guidelines and elicit their perspectives on the effects of guidelines on clinical decisions.
Semistructured face-to-face interviews were undertaken with 19 nephrologists from a variety of clinical settings across Australia. Participants were asked about their views of clinical practice guidelines in nephrology, both local (Caring for Australasians With Renal Impairment [CARI]) and international, and their opinions of other factors that shape their decision making. Interviews were recorded, transcribed, and analyzed qualitatively.
4 major themes were identified. First, overall, the nephrologists interviewed trusted the CARI guideline process and output. Second, guidelines served a variety of purposes, providing a good summary of evidence, a foundation for practice, an educational resource, and justification for funding requests to policy makers, as well as promoting patient adherence to treatment. Third, guidelines were only one input into decision making. Other inputs included individual patient quality of life and circumstances, opinion leaders, peers, nephrologists' own experiences, the regulation and subsidy framework for drugs and devices, policies and work practices of the local unit, and other sources of evidence. Fourth, guideline uptake varied. Factors that favored the use of guidelines included having a strong evidence base, being current, including specific targets and an explicit treatment algorithm, being sent frequent reminders, and having local peer support for implementation and the necessary personnel and other resources for effective implementation.
Evidence-based guidelines appear to impact strongly on clinical decision making of Australian nephrologists, but are only one input. Improvements in the evidence that underpins guidelines and improvements in the content and formatting of guidelines are likely to make them more influential on decision making. Trust in the guideline groups' processes is a prerequisite for implementation.
在包括肾脏病学在内的所有医学学科中，基于证据的指南推荐与临床实践之间始终存在差距。本研究旨在探讨肾脏病专家对指南的看法，并了解他们对指南对临床决策影响的看法。
在澳大利亚各地的各种临床环境中，对 19 名肾脏病专家进行了半结构化的面对面访谈。要求参与者就肾脏病学中的临床实践指南（包括当地的《照顾澳大拉西亚肾脏病患者指南》（Caring for Australasians With Renal Impairment [CARI]）和国际指南）以及影响他们决策的其他因素发表意见。对访谈进行了录音、转录和定性分析。
确定了 4 个主要主题。首先，总的来说，接受采访的肾脏病专家信任 CARI 指南的过程和结果。其次，指南有多种用途，为证据提供了很好的总结，为实践奠定了基础，是一种教育资源，并为向决策者提出资金请求提供了依据，同时也促进了患者对治疗的依从性。第三，指南只是决策的一个输入。其他输入包括患者个体的生活质量和情况、意见领袖、同行、肾脏病专家自己的经验、药物和设备的监管和补贴框架、当地单位的政策和工作实践以及其他来源的证据。第四，指南的采用情况各不相同。有利于使用指南的因素包括具有强大的证据基础、内容最新、包含具体目标和明确的治疗算法、频繁收到提醒、以及当地同行的支持以实施以及有效实施所需的人员和其他资源。
基于证据的指南似乎对澳大利亚肾脏病专家的临床决策有很大影响，但只是一个输入。改善指南所依据的证据以及指南的内容和格式可能会使其对决策产生更大的影响。对指南小组流程的信任是实施的前提条件。
