Applying clinical guidelines in general practice: a qualitative study of potential complications

Abstract

BackgroundClinical guidelines for single diseases often pose problems in general practice work with multimorbid patients. However, little research focuses on how general practice is affected by the demand to follow multiple guidelines. This study explored Norwegian general practitioners’ (GPs’) experiences with and reflections upon the consequences for general practice of applying multiple guidelines.MethodsQualitative focus group study carried out in Mid-Norway. The study involved a purposeful sample of 25 Norwegian GPs from four pre-existing groups. Interviews were audio-recorded, transcribed and analyzed using systematic text condensation, i.e. applying a phenomenological approach.ResultsThe GPs’ responses clustered around two major topics: 1) Complications for the GPs of applying multiple guidelines; and, 2) Complications for their patients when GPs apply multiple guidelines. For the GPs, applying multiple guidelines created a highly problematic situation as they felt obliged to implement guidelines that were not suited to their patients: too often, the map and the terrain did not match. They also experienced greater insecurity regarding their own practice which, they admitted, resulted in an increased tendency to practice ‘defensive medicine’. For their patients, the GPs experienced that applying multiple guidelines increased the risk of polypharmacy, excessive non-pharmacological recommendations, a tendency toward medicalization and, for some, a reduction in quality of life.ConclusionsThe GPs experienced negative consequences when obliged to apply a variety of single disease guidelines to multimorbid patients, including increased risk of polypharmacy and overtreatment. We believe patient-centered care and the GPs’ courage to non-comply when necessary may aid in reducing these risks. Health care authorities and guideline developers need to be aware of the potential negative effects of applying a single disease focus in general practice, where multimorbidity is highly prevalent.

The clinical database and implementation of treatment guidelines by the Danish Breast Cancer Cooperative Group in 2007–2016

“…We only monitored a small sample of revisions introduced in the last decade, and those included were better defined than those remaining. We did not assess comorbidity in this study and multimorbidity involves a variety of challenges and may to some degree have limited implementation [36]. Further, regional differences have not been investigated.…”

<p>Patterns of Multimorbidity and Differences in Healthcare Utilization and Complexity Among Acutely Hospitalized Medical Patients (≥65 Years) – A Latent Class Approach</p>

“…However, studies of the GPs´experience with treating patients with multimorbidity, show that the GPs´experience many barriers. 3,58,59 These include structural barriers of short time consultations, which makes it difficult to treat the whole patient and not just one problem. 3,59 This can be easily dealt with by agreeing on longer consultations and payment hereof.…”

“…But there are also barriers related to the medical treatment. 3,58,59 In Denmark, GPs manage over 80% of all prescribed drugs, 60 however many physicians have difficulties with deprescribing drugs not prescribed by themselves and hence, contribute to an accumulation of prescribed drugs and a complex medical regime for the patient. 61 In this study, the number of redeemed prescriptions ranged from 4 ("Minimal chronic conditions" and "Neurological and vascular disorders") to 17 ("Complex multimorbidity") for women and from 3 ("Neurological and vascular disorders") to 15 ("Degenerative and pulmonary disorders") for men.…”

Applying evidence-based medicine in general practice: a video-stimulated interview study on workplace-based observation

“…Applying evidence-based medicine (EBM) in practicedefined as combining clinical expertise, patient preferences and the best-available evidence when making decisions for individual patientsis important but hard to do [1][2][3]. EBM is taught according to the five steps defined in the Sicily Statement: ask, acquire, appraise, apply and evaluate [4].…”