National clinical guidelines for treatment of cardiovascular disease in primary care
Many studies have demonstrated the lack of adherence to clinical guidelines which may lead to suboptimal diagnosis and care of patients.
This has also been observed in Sweden and there have been efforts in recent years to remedy this, including through the creation of various quality registers and quality indicators. However, many believe that it is cumbersome and time consuming to compile and enter information into different types of records and that the care cannot fully take advantage of the various quality indicators that are still produced.
To support quality work in primary care, the Swedish Society of Family Medicine (SFAM) has developed simple, measurable and evidence-based quality indicators and target values for these, which define the desired results to achieve a good quality of the treatment of various common diseases. Based on those quality indicators an Internet-based instrument (pvkvalitet.se) was created where primary care units can record their data on a small sample (50-60) of patients, and compare their results with other units. These comparisons are only made at an aggregated level and cannot be used at the individual patient visit at the time of decision making.
Summary and feedback of physician and nursing unit's own performance (audit and feedback) is, according to international studies, an evidence-based way to stimulate improvement and increase adherence to clinical guidelines, but it is also shown that higher efficiency can be achieved with decision support that provides information at the time of decision making. Knowledge and time constraints are known barriers for the implementation and adherence to evidence-based clinical guidelines, and it takes a long time after that new guidelines published until they are implemented in practice. To reduce the discrepancy between evidence and practice suggests the use of computerized decision support systems for clinical guidelines.
There are various methods and techniques to formalize the knowledge contained in the guidelines and create models that can be interpreted by computers. The guidelines are then presented in the form of passive or active decision support systems, eg in the form of warnings if the user does not follow the guideline. In general, these systems do not capture the reason for deviation from the guideline that might be clinically relevant. From a health and learning perspective, it is important to capture precisely the cause of the deviation and to find strategies to deal with them in order to increase adherence to guidelines in these cases.
Our hypothesis is that the development of knowledge in primary care can be significantly improved when describing the cause of deviations from clinical guidelines through systematic data collection and finding strategies to prevent such. Today, there is no systematic mapping and cause inventory to be made solely by means of follow-up meetings with staff.
The project is limited to national clinical guidelines for three cardiovascular diseases (Coronary Heart Disease, Heart Failure and Atrial Fibrillation) and consists of two parts:
Part I is a systematic descriptive study of the inventory of the occurrence of deviations from clinical guidelines (baseline) and reasons for these deviations captured at six primary care centers.
Part II is a controlled intervention study where the intervention is composed of three parts: education, decision support and documented justification of the reasons for deviation from the guidelines.
The project is lead by Gunnar Nilsson, Centre for Family Medicine (CeFam) and is financed by the Strategic Research Area Care Sciences (SFO-V) at KI. For HIC, Sabine Koch is involved in the project.