James P A, Cowan T M, Graham R P, Majeroni B A, Fox C H, Jaén C R
Office of Rural Health, State University of New York at Buffalo, USA.
J Am Board Fam Pract. 1997 May-Jun;10(3):206-12.
Effective clinical practice guidelines should improve clinical outcomes, and measures of physician use of clinical practice guidelines should correlate with improved outcomes. This study translates a clinical practice guideline on heart failure into review criteria to measure physician performance and the effectiveness of the clinical practice guideline.
A panel of 11 family physicians and 1 cardiologist systematically reviewed the clinical practice guideline for its clinical importance, educational relevance, and evaluative appropriateness. Then a subset of 4 family physicians rigorously applied each recommendation to established criteria for measurability and developed an evaluation tool useful in medical record review.
The heart failure clinical practice guideline was found to be an excellent educational tool. Using it to measure physician performance, however, was limited to diagnostic tests and drug prescribing. Of 45 recommendations, 5 fulfilled criteria for measurability; 1 recommendation had A-level evidence, whereas 2 recommendations had B-level and 2 had C-level evidence.
This study illustrates the logistic issues and challenges in developing a measure of physician adherence to clinical practice guidelines. Medical record review is inadequate to measure many recommendations. Physicians use of this clinical practice guideline must be evaluated as an intermediate step to measuring the effectiveness of clinical practice guidelines based on patient outcomes.
有效的临床实践指南应改善临床结局，并且衡量医生对临床实践指南的应用情况的指标应与改善的结局相关。本研究将一项关于心力衰竭的临床实践指南转化为审查标准，以衡量医生的表现以及该临床实践指南的有效性。
由11名家庭医生和1名心脏病专家组成的小组系统地审查了该临床实践指南的临床重要性、教育相关性和评估适宜性。然后，4名家庭医生组成的一个子集严格将每项建议应用于既定的可衡量标准，并开发了一种有助于病历审查的评估工具。
心力衰竭临床实践指南被发现是一个优秀的教育工具。然而，用它来衡量医生的表现仅限于诊断测试和药物处方。在45项建议中，5项符合可衡量标准；1项建议有A级证据，2项建议有B级证据，2项建议有C级证据。
本研究说明了在制定衡量医生对临床实践指南依从性的指标时存在的后勤问题和挑战。病历审查不足以衡量许多建议。必须将医生对该临床实践指南的应用作为基于患者结局衡量临床实践指南有效性的中间步骤来进行评估。
