1. A practical focus
CPGs are tools that can help health care practitioners deliver high-quality care by outlining best practices based on available evidence and expert opinion. CPGs have the potential to reduce variation and improve appropriateness and, thus, efficiency of care. Although CPGs have been in use for many years, they have gained prominence in the last 2 decades as a result of the profusion of scientifically derived information, evidence that substantial variations in practice patterns exist and increasing concern that health care is not always delivered as efficiently as possible.
Despite their increasing prominence, CPGs are not being used to their fullest potential by practitioners. In a recently published survey of Canadian physicians,2 most respondents indicated that they were moderately or strongly confident about guidelines developed by recognized or credible physician groups. However, only 14% of respondents used CPGs on a daily or weekly basis, and less than 40% reported that a CPG had actually changed how they practised within the last year. This survey corroborated a survey of internists conducted 2 years earlier in the United States, where only 18% of those surveyed indicated that a CPG changed their practice pattern.3 The results of these surveys suggest that the reason physicians do not use CPGs to their fullest potential is not negative attitudes about them, but a lack of practical implementation strategies that allow physicians to incorporate them into their practice patterns.
National, provincial and local perspectives
At the 1996 CPG implementation workshop, panel members echoed the need for practical strategies to address challenges related to implementing CPGs in physicians' practice settings. Panelists provided 3 perspectives: national, provincial and local.
- Ms. Donna Lillie, director of research and professional education, Canadian Diabetes Association, described lessons learned through the implementation of a successful national program. She emphasized collaborative partnerships as the critical success factor in her association's CPG activities. She also mentioned the importance of openly addressing such issues as education credits, partnership financing, authority to influence behaviour change and confidentiality and access issues related to evaluation through chart audits.
- Dr. Stewart McMillan, chair of the Health Services Utilization and Research Commission, Saskatoon, Saskatchewan, provided both a provincial perspective and that of a family physician. He described 6 CPGs that the commission has been involved in disseminating, the techniques employed and supportive and restrictive factors influencing implementation. Supportive factors included up-front assessments of practitioners' interests, incentives for implementation and the use of short CPGs or the inclusion of summary reports with longer CPGs. Factors inhibiting uptake included a nonsupportive environment and trying to influence behaviour with new technology that is not yet ingrained in a practice.
- Ms. Carol Kelsey provided a local perspective based on her experience as coordinator of a hospital-based CPG project in Oshawa, Ontario. She focused on the need for continuing, sensitive communication among health professionals and for recognition of the critical roles that all health care team members play in implementing CPGs. Ms. Kelsey emphasized the importance of a process to build local ownership of CPGs and the need for careful coordination of multiple implementation strategies designed to predispose practitioners to their use.
A national CPG database
In 1992 the CMA undertook the task of collecting information on CPGs developed in Canada by national or provincial/territorial medical and health organizations, governments and expert working groups. In 1994, it published the first Directory of Canadian clinical practice guidelines,4 which contained information on over 500 CPGs. It now maintains a database of over 1400 CPGs developed or reviewed since 1990 by over 80 recognized expert organizations and groups and is in the process of developing an electronic version (CPG Infobase) for full text distribution over the Internet. The first stage of the CPG Infobase, which currently contains the full text of over 200 guidelines, is available on CMA Online. More CPGs will be added as the CMA collaborates with other CPG developers and mounts the full text at its site, or points to the full text if it is available at another site. A search engine will also be added to help users find the appropriate guideline.For the future
Significant progress has been made since organizations began developing CPGs in the 1970s and 80s. Canadian physicians now have a set of national principles to guide their CPG efforts.1 They have also discussed and brought to the forefront some of the more difficult issues in the CPG process. Nonetheless, no matter how well guidelines are developed, unless they are actually used by practitioners during clinical encounters, their impact in terms of improving clinical practice will be minimal. Later in this handbook, we describe key CPG implementation challenges in 6 settings and suggest practical strategies for addressing them.Perhaps the next step in maintaining and improving quality health care through the CPG process is to focus on evaluation, information systems and measurement. Without an evaluation of the quality of care provided, it is difficult to determine how effective a guideline is in improving the process or outcome of care. Feedback from evaluations can be used to modify, adapt or create new guidelines, making this an essential step in the process (Figure 1).
