The effects of clinical practice guidelines on patient outcomes in primary care: a systematic review.

OBJECTIVE To assess the evidence for the effectiveness of clinical practice guidelines (CPGs) in improving patient outcomes in primary care. DATA SOURCES 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." STUDY SELECTION 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. DATA EXTRACTION 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). DATA SYNTHESIS 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. CONCLUSION 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.

[1]  R. Grol,et al.  Development of guidelines for general practice care. , 1993, The British journal of general practice : the journal of the Royal College of General Practitioners.

[2]  R. Grol.  Implementing guidelines in general practice care. , 1992, Quality in health care : QHC.

[3]  R J Lilford,et al.  Effect of using protocols on medical care: randomised trial of three methods of taking an antenatal history. , 1992, BMJ.

[4]  T. Coates,et al.  Management of hypertension in private practice: A randomized controlled trial in continuing medical education , 1988 .

[5]  S. Oparil,et al.  Treatment of hypertension by computer and physician-a prospective controlled study. , 1977, Journal of chronic diseases.

[6]  Albert R. Martin,et al.  Training physicians in counseling about smoking cessation. A randomized trial of the "Quit for Life" program. , 1989, Annals of internal medicine.

[7]  H. Covvey,et al.  Randomised controlled trial of computer assisted management of hypertension in primary care. , 1986, British medical journal.

[8]  J. Grimshaw,et al.  Do clinical guidelines improve general practice management and referral of infertile couples? , 1993, BMJ.

[9]  D. Taylor,et al.  A randomized trial of a family physician intervention for smoking cessation. , 1988, JAMA.

[10]  D. Sackett,et al.  The Ends of Human Life: Medical Ethics in a Liberal Polity , 1992, Annals of Internal Medicine.

[11]  R B Haynes,et al.  Does a mailed continuing education program improve physician performance? Results of a randomized trial in antihypertensive care. , 1986, JAMA.

[12]  H. Anderson,et al.  Randomized controlled trial of small group education on the outcome of chronic asthma in general practice. , 1989, The Journal of the Royal College of General Practitioners.

[13]  A D Oxman,et al.  No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. , 1995, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[14]  R. Putnam,et al.  Physicians' participation in establishing criteria for hypertension management in the office: will patient outcomes be improved? , 1989, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[15]  A D Oxman,et al.  Changing physician performance. A systematic review of the effect of continuing medical education strategies. , 1995, JAMA.

[16]  P Ours,et al.  DIABEDS: a randomized trial of the effects of physician and/or patient education on diabetes patient outcomes. , 1987, Journal of chronic diseases.

[17]  C. McDonald,et al.  Reminders to physicians from an introspective computer medical record. A two-year randomized trial. , 1984, Annals of internal medicine.

[18]  P M Wortman,et al.  Medical Information Systems: Assessing Impact in the Areas of Hypertension, Obesity and Renal Disease , 1982, Medical care.

[19]  David M. Eddy,et al.  A Manual for Assessing Health Practices & Designing Practice Policies: The Explicit Approach , 1992 .

[20]  A. Basiński.  Evaluation of clinical practice guidelines. , 1995, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[21]  P. White,et al.  Using information from asthma patients: a trial of information feedback in primary care , 1995, BMJ.

[22]  G. Barnett,et al.  Limitations of provider interventions in hypertension quality assurance. , 1985, American journal of public health.