A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003)
A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003)
Description
This report focused on inappropriate pathology testing in health care and how best to facilitate evidence-based best practice in the face of rapidly expanding knowledge, rising consumer expectations and government concerns about unsustainable increases in health costs.
Grant Recipient
Therapeutic Guidelines Ltd
Aim
to recommend a mechanism for the development, implementation and evaluation of evidence-based, best practice clinical guidelines to facilitate quality use of pathology.
This aim was achieved by this project.
Findings
The literature review revealed that guidelines alone are usually unsuccessful in implementing practice change.
A mechanism is required to coordinate and link pathology guidelines development, software vendors and educational service providers.
Clinicians and consumers want integrated and consistent knowledge resources (pathology and/or radiological examinations, therapeutic and/or preventative management and patient education), not a number of overlapping and inconsistent resources in different formats lacking a common clinical problem index.
Core clinical guidelines resources should be:
accessible from the health worker’s electronic desktop (general practice [GP] and hospital practice)
entered through a common clinical problem (including common synonyms)
ultimately be capable of assisting recommended actions.
Various levels of computerised decision support are possible.
Consumers want better communication with their health providers about diagnostic tests, and many would appreciate the opportunity to access consumer friendly information about tests recommended, including their limitations and implications of likely results.
There are varied views about the content and format of best practice clinical guidelines for the ordering of pathology tests.
It is difficult for GPs to distil evidence-based, best practice recommendations from the increasing volumes of scientific literature.
An important consideration is the limited research base when it comes to the appropriate use of pathology and best practice.
A number of studies reported a reduction in pathology testing rates after guidelines were introduced into Australian hospitals.
Recommendations
Develop a mechanism for the development of pathology guidelines.
Develop an appropriate format for the guidelines.
Disseminate and implement the guidelines.
Incorporate the guidelines into computer decision support systems.
Assess practitioner acceptance of the guidelines.
Assess the effectiveness of guidelines in influencing patient outcomes.
Develop related patient educational material.
Principles guiding this report’s recommendations were:
The mechanism should ensure that pathology guidelines are produced according to best-practice principles.
The mechanism should bring together key information providers who currently provide recommendations concerning pathology tests in order to facilitate consistency of recommendations and avoid unnecessary duplication of effort.
The mechanisms should facilitate (over a longer time-frame) the integration of electronic pathology guidelines into more comprehensive, machine readable, electronic information resources to enable computerised point-of-care decision support and practice evaluation. This will require bringing together pathology and other professionals to achieve this.
The mechanism needs to augment print and electronic pathology guidelines with holistic, multi-dimensional education programs to achieve change.
Areas for Future Consideration
Develop evidence-based, best practice guidelines for the appropriate use of pathology for GPs.
Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004)
Description
This project sought to demonstrate proof-of-concept for a national program for more informed use of the Prostate Specific Antigen (PSA) test by Australian practitioners, and to further investigate the usefulness of academic detailing (AD) for support of better outcomes from the use of diagnostic technologies. This was an extension of work on the Commonwealth of Australia’s proof-of-concept project for a national program for more informed use of the PSA test by Australian General Practitioners (GPs): 1 February 2001 to 31 August 2003. It also incorporated information from the study on colorectal cancer and Helicobacter pylori (H. Pylori) visiting programmes.
Grant Recipient
Drug and Therapeutics Information Service (DATIS)
Aims and Objectives
to demonstrate proof-of-concept for a national program for more informed use of the PSA test by Australian practitioners
to further investigate usefulness of academic detailing for support of better outcomes from the use of diagnostic technologies.
These aims and objectives were achieved by this project.
Approximately 50% of GPs (n=162) surveyed in Melbourne adhered to the current Australian guidelines with respect to PSA screening.
Many GPs did not support the idea of PSA screening for a variety of reasons although they view early knowledge of prostate cancer as beneficial, regardless of what the guidelines or evidence propose.
Many GPs are still likely to be influenced by their own anecdotal experience.
Many GPs are confused regarding the controversy and potential risks and benefits of PSA screening, and there was uncertainty about ‘which way to go’ when faced with a patient request for PSA screening.
Only a very small number of GPs were interested in alternative PSA measurements (e.g. free to total PSA, PSA velocity), or in the concepts of sensitivity, specificity and positive predictive value (PPV).
Medico-legal issues are a major influence on GPs fulfilling patient requests for PSA screening. The potential long-term influence of this is the standard of care offered by GPs may ultimately be determined by fear of medico-legal repercussions rather than being based on best practice.
GPs with younger patients tended to order fewer PSA tests, while GPs with older patients tended to order more.
Many GPs supported shared decision-making and recognised the importance of helping patients understand the benefits and risks of PSA screening.
Many GPs found written material advantageous in assisting with shared decision making, while the electronic delivery mode of information was not an important issue.
A high proportion of GPs commented favourably on the Mr. PHIP materials.
Many GPs wanted to retain the visual detailing cards from the prostate cancer topic.
Many GPs affirmed that in the current medico-legal climate regarding PSA testing it was more important than ever to be aware of the evidence and to remain ‘balanced and sensible’ about the screening issue.
It took three or four visits by DATIS to change GP behaviour or attitude to PSA screening (recorded during colorectal cancer screening visits).
Colorectal Cancer Screening
There was mixed used of colorectal screening amongst GPs.
There was increased interest in colorectal screening, especially the faecal occult blood test (FOBT) after the DATIS visits.
There were mixed concerns about the different screening methods in terms of patient experience and barriers to using them e.g. diet restrictions, handling stools.
A small proportion of GPs asked to keep the DATIS detailing aids.
There was mixed responses to the Mr PHIP materials.
Gastro-oesophageal reflux disease (GORD), non-ulcer dyspepsia (NUD) and non-steroidal anti-inflammatory drugs (NSAIDS) were issues related to H. pylori that GPs were uncertain about.
Many GPs used proton pump inhibitors (PPIs) as an initial strategy for uninvestigated non-GORD dyspepsia.
The most established and frequently used non-invasive H. pylori test was the urea breath test (UBT).
There was mixed reactions to the “test & treat” or “search & treat” strategies for long-term PPI users.
May GPs agreed that PPIs were overused and short-term use can lead to long-term use.
Many GPs viewed serology favourably on the second DATIS visit.
Overall
(Only the findings relevant to pathology have been included as opposed to findings specifically related to the DATIS service.)
The DATIS academic detailing program on the topics of pathology tests in prostate cancer, colorectal cancer, type 2 diabetes (not included in this report) and H. Pylori infection has a high acceptability amongst GP in different Australian States and was effective in improving GP’s knowledge and self-reported practice.
Participating GPs highly valued the DATIS educational visits and materials. A common thread in feedback from GPs was they valued the information provided in terms of its impartiality, clinical relevance, practicality, thorough research and method of presentation.
Recommendations
A national strategy for achieving more informed choices between GPs and their patients with respect to prostate cancer issues is urgently needed in contemporary Australia.
DATIS service-oriented-AD is a methodology suitable to be used as a foundation within a needed national strategy. It has been shown to be effective in the 1998-99 study relative to cheaper approaches which were found to be ineffective.
A number of uncertainties about DATIS service-oriented-AD in this context need to be examined before experimentally derived evidence about the effectiveness of DATIS methods could reasonably be translated into public health policy action.
Key Project Learnings
Medico-legal aspects of PSA screening were a major issue for the majority of GPs visited, and perhaps the greatest single motivator as to why GPs fulfill patient requests for the PSA test.
Many GPs feel vulnerable and unconfident when dealing with the issues and controversy surround prostate cancer screening.
