Worrall G, Chaulk P, Freake D
Centre for Rural Health Studies, Whitbourne, Nfld.
CMAJ. 1997 Jun 15;156(12):1705-12.
To assess the evidence for the effectiveness of clinical practice guidelines (CPGs) in improving patient outcomes in primary care.
A search of the MEDLINE, HEALTHPLAN, CINAHL and FAMLI databases was conducted to identify studies published between Jan. 1, 1980, and Dec. 31, 1995, concerning the use of guidelines in primary medical care. The keywords used in the search were "clinical guidelines," "primary care," "clinical care," "intervention," "randomized controlled trial" and "effectiveness."
Studies of the use of CPGs were selected if they involved a randomized experimental or quasi-experimental method, concerned primary care, were related to clinical care and examined patient outcomes. Of 91 trials of CPGs identified through the search, 13 met the criteria for inclusion in the critical appraisal.
The following data were extracted, when possible, from the 13 trials: country and setting, number of physicians, number of patients (and the proportion followed to completion), length of follow-up, study method (including random assignment method), type of intervention, medical condition treated and effect on patient outcomes (including clinical and statistical significance, with confidence intervals).
The most common conditions studied were hypertension (7 studies), asthma (2 studies) and cigarette smoking (2 studies). Four of the studies followed nationally developed guidelines, and 9 used locally developed guidelines. Six studies involved computerized or automated reminder systems, whereas the others relied on small-group workshops and education sessions. Only 5 of the 13 trials (38%) produced statistically significant results.
There is very little evidence that the use of CPGs improves patient outcomes in primary medical care, but most studies published to date have used older guidelines and methods, which may have been insensitive to small changes in outcomes. Research is needed to determine whether the newer, evidence-based CPGs have an effect on patient outcomes.
评估临床实践指南（CPGs）在改善初级保健患者结局方面有效性的证据。
对MEDLINE、HEALTHPLAN、CINAHL和FAMLI数据库进行检索，以识别1980年1月1日至1995年12月31日期间发表的有关初级医疗保健中指南使用的研究。检索使用的关键词为“临床指南”“初级保健”“临床护理”“干预”“随机对照试验”和“有效性”。
如果CPGs使用研究涉及随机实验或准实验方法、关注初级保健、与临床护理相关且检查了患者结局，则选择这些研究。通过检索确定的91项CPGs试验中，有13项符合纳入批判性评价的标准。
尽可能从这13项试验中提取以下数据：国家和环境、医生数量、患者数量（以及完成随访的比例）、随访时间、研究方法（包括随机分配方法）、干预类型、治疗的医疗状况以及对患者结局的影响（包括临床和统计学意义及置信区间）。
研究最多的常见疾病是高血压（7项研究）、哮喘（2项研究）和吸烟（2项研究）。其中4项研究遵循国家制定的指南，9项使用当地制定的指南。6项研究涉及计算机化或自动化提醒系统，其他研究则依赖小组研讨会和教育课程。13项试验中只有5项（38%）产生了具有统计学意义的结果。
几乎没有证据表明CPGs的使用能改善初级医疗保健中的患者结局，但迄今为止发表的大多数研究使用的是较旧的指南和方法，这些可能对结局的微小变化不敏感。需要进行研究以确定更新的、基于证据的CPGs是否对患者结局有影响。
