Discrepancies exist between general practitioners’ clinical work and a guidelines implementation programme

Editor—Doctors need information on how to manage their patients’ problems many times each day; one estimate was as high as three or four times per case.¹ The problem of how to ensure that doctors base management on sound evidence has been widely debated in recent years. One approach is evidence based medicine, in which patients’ problems are formulated into structured, answerable questions for which evidence is sought, found, appraised, and applied.² Another is the implementation of evidence based guidelines, which expert groups compile and implement by a process of education and audit.³

In Newcastle and North Tyneside five priority areas were identified for implementation in 1996-7—angina, atrial fibrillation, eradication of Helicobacter pylori, schizophrenia, and prophylaxis of deep vein thrombosis in surgical patients.⁴ I was interested to find out what proportion of general practitioners’ clinical work might be influenced by the implementation of guidelines in the priority areas.

A total of 13 general practitioners in Newcastle West agreed to log 40 consecutive presentations of problems in routine surgeries between October 1996 and January 1997. The doctors were asked simply to record what they saw. The results obtained from the 11 general practitioners who responded are summarised in the table. The key findings are that problems in the five priority areas occurred in 12 out of 413 presentations and that the total number of different problems was 158. The most common problem in this sample was depression, but even this “common” problem only presented 19 times.

It is not surprising that the proportion of consultations in which the guidelines could be used is so low—the most recent Morbidity statistics from general practice found that these priority areas presented in 3.8% of consultations.⁵ The sheer variety and number of problems presenting to general practitioners even in this small sample, however, represent a daunting challenge. Guidelines for the 10 most common conditions would have covered about one third of consultations, but 36 guidelines would have been required to cover two thirds. Altogether 122 different problems presented in the remaining third, including congestive cardiac failure, diabetes mellitus, reflux oesophagitis, schizophrenia, rectal bleeding, cerebrovascular accident, pelvic infection, and request for measurement of prostate specific antigen. Complex or serious problems may each present infrequently, but together they form a substantial part of the workload in general practice. Strategies for promoting clinical effectiveness in general practice should address the need for evidence to inform the management of multiple problems presenting in daily practice.

Table.

Analysis of 413 presentations to 11 general practitioners in Newcastle West

	Problems	Presentations (%)
Total No of problems presented	158	413 (100)
10 most common problems	10	134 (32.4)
Priority problems in guidelines implementation programme*	5	12 (2.9)
Problems presenting three to 10 times	26	130 (31.5)
Problems presenting twice	27	54 (13.1)
Problems presenting once	95	95 (23.0)

^*Criteria for choosing priority areas were: common problem, local health priority, sound evidence base for practice, known variation, and involved hospital and primary care. Prophylaxis of deep vein thrombosis in surgical patients did not fit the final criterion but was considered important enough and had a sound enough evidence base to be implemented in hospitals.