A review of clinical practice guidelines found that they were often based on evidence of uncertain relevance to primary care patients

Abstract

ObjectivesPrimary care patients typically have less severe illness than those in hospital and may be overtreated if clinical guideline evidence is inappropriately generalized. We aimed to assess whether guideline recommendations for primary care were based on relevant research.Study Design and SettingLiterature review of all publications cited in support of National Institute for Health and Care Excellence (NICE) recommendations for primary care. The relevance to primary care of all 45 NICE clinical guidelines published in 2010 and 2011, and their recommendations, was assessed by an expert panel.ResultsTwenty-two of 45 NICE clinical guidelines published in 2010 and 2011 were relevant to primary care. These 22 guidelines contained 1,185 recommendations, of which 495 were relevant to primary care, and cited evidence from 1,573 research publications. Of these cited publications, 590 (38%, range by guideline 6–74%) were based on patients typical of primary care.ConclusionNearly two-third (62%) of publications cited to support primary care recommendations were of uncertain relevance to patients in primary care. Guideline development groups should more clearly identify which recommendations are intended for primary care and uncertainties about the relevance of the supporting evidence to primary care patients, to avoid potential overtreatment.

Alcoholic versus aqueous chlorhexidine for skin antisepsis: the AVALANCHE trial

“…38,39 However, it is important that clinical guidelines used in general practice be informed by primary care evidence, so that they will be directly applicable to patients who present to the general practitioner. 40 The study had some limitations. The baseline infection rate was lower than we predicted on the basis of previous studies.…”

Primary care evidence in clinical guidelines: a mixed methods study of practitioners’ views

“…23 First, participants were presented with the full text of 14 primary care-relevant recommendations taken from various NICE guidelines, and asked to rate each recommendation on a scale of 1 to 9 for applicability to their primary care patients, with 1 being not likely to use with their patients, and 9 being highly likely to use. An electronic link to each full NICE guideline was given for reference.…”

“…The applicability of evidence for each recommendation was rated as low if evidence for the recommendation was supported by no studies conducted on primary care or community populations, medium if supported by up to half of the studies, and high if the majority of the studies cited as evidence had their participants selected from primary care or the community, as described elsewhere. 23 Recommendations were presented in the survey in a random order.…”

“…21 The authors have previously reported that NICE guideline recommendations for primary care were not always based on research conducted on, or generalisable to, primary care populations. 22,23 This study aimed to find out whether that mattered to primary care practitioners. This study therefore aimed to explore primary care practitioners' views of the applicability of primary care evidence in NICE guidelines.…”

International variation in adherence to referral guidelines for suspected cancer: a secondary analysis of survey data

“…[1][2][3][4][5][6][7][8] Many countries have guidelines to advise primary care practitioners on the symptoms and signs of potential oncological significance that will require investigation or referral. 9 However, these guidelines lack a robust primary care evidence base 10,11 and commentators caution that they are 'guidelines not tramlines'. 12 The five-day reduction in diagnostic delay observed in the UK since the introduction of the 2005 National Institute for Health and Care Excellence (NICE) guidelines for managing suspected cancer suggests that guidelines are important, but substantial variation persists in the median diagnostic interval between cancer types (26-156 days).…”