The best care for the least advantaged

With background training in public health and anthropology, Associate Professor Christine Phillips has devoted her professional life to improving the standards of primary health care for some of the most vulnerable people in society. Her extensive body of work has examined the roles of nurses in general practice, how primary care can prepare itself for pandemics of disease, and the specific healthcare needs of refugees and recent migrants. In 2012, Associate Professor Phillips received a grant from Therapeutic Guidelines Limited (TGL) and the RACGP Foundation to study the way frontline healthcare practitioners use professional guidelines when working with patients affected by chronic diseases. Seeking a more nuanced understanding of the reasons doctors and nurses sometimes deviate from published medical guidelines, the research would investigate decision-making processes employed by Australian general practice clinicians in relation to the treatment of diabetes, renal failure, chronic respiratory diseases, as well as chronic heart failure.

Clinical guidelines in the real world

Guidelines are an attempt to transfer what is learned through research into routine clinical practice, attempting to gather and frame the available evidence in ways that are accessible and functional for both doctors and nurses. According to one estimate as many as 1000 clinical guidelines were produced between 2005 and 2013 for use in Australia alone. As Associate Professor Phillips notes, “…this raises many challenges for primary care clinicians in appraising, filtering and accessing high quality evidence-based information in a timely fashion that can aid decision making.” Two main questions appealed to Associate Professor Phillips: how do clinical practitioners use these guidelines in their patient care decisions in the context of their experience and training, and what specific qualities make a guideline more or less effective and useful? The answers to these questions would have important implications for both the use and implementation of clinical guidelines throughout the healthcare system.

Previous research has acknowledged that clinical guidelines can be important in improving the quality of care patients receive, but also that they have problems with implementation and uptake. Evidence that guidelines for the treatment of several chronic conditions are underused suggests they may not be meeting the needs of doctors and nurses on the frontlines. Associate Professor Phillips interviewed 41 general practice doctors and 19 nurses, with each of them answering a series of questions about simulated cases. As the cases developed from diagnosis to management and then further complications, the clinicians reflected aloud on their decision making. Participants were also asked how their decisions would change after factoring in contextual information about the patient. From these interviews Associate Professor Phillips was able to discern a common pattern for decision making that involved three stages: weighing the guidelines against the clinical situation; a decision to concur with or contest the recommendations; choosing a course of action that may or may not apply all of the available guidelines.

The research revealed that experienced clinicians tended to have a mental model of ‘correct treatment’ that quite accurately reflected the recommended guidelines. For example, in 78% of the simulated cases, the clinician’s mental model incorporated the central elements of the guidelines. Respondents were most likely to have mental models that matched guidelines in the case of diabetes (92%) and chronic heart failure (90%), while the mental models that displayed most variation from the guidelines were for chronic kidney disease (54%). These findings reflect the high level of awareness and education that exists for some diseases but not others. Interestingly, respondents who had a low level of familiarity with the guidelines still displayed good knowledge of their key principles, suggesting that this information had reached them in other ways.

Deviations from the regulations were largely caused by contextual factors rather than disagreement with the recommended course of action. Assessing the performance of doctors and nurses by measuring their adherence to clinical guidelines is problematic, as it ignores their efforts to place patients at the centre of decision-making. Factors such as family situations, overall health, self-care abilities, work needs, and socioeconomic status all had an impact on a clinician’s decision to stray from prescribed guidelines. The insights gleaned from this research will have an important influence in the way guidelines are formulated in the future, and the need to take into account the decision-making processes of those performing primary care roles.

Making guidelines work better

Ultimately, the goal of Associate Professor Phillips’ research was to help improve the overall quality and usefulness of clinical guidelines. A significant portion of this project involved the analysis of 66 guidelines available through the National Health and Medical Research Council (NHMRC) web portal. The researchers used a set of criteria to determine the purpose of each guideline, such as improve management of a condition, increase early diagnosis, prevent disease, provide more effective treatment, and its ultimate effectiveness. Almost a quarter of the guidelines they reviewed failed to meet their final purpose, often because their design, processes, or materials were not aligned to the claimed objective. The best guidelines were simple, used clear language and were strongly aligned to evidence.

Meanwhile, the research revealed the strong need for easy accessibility in the workplace, perhaps through smartphone apps or software. The work of Associate Professor Phillips and her team, proudly cofunded by Therapeutic Guidelines Limited and the RACGP Foundation, will help ensure that future guidelines work better for both doctors and patients, leading to improved outcomes across the health system.

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