Clinical guidelines are recommendations targeted at medical professionals which aim to optimise patient care. When successfully implemented, clinical guidelines have been shown to improve processes of care and clinical outcomes. However, clinical guidelines are often not successfully implemented and there exists a significant variation in rates of compliance between different doctors. Factors which affect compliance fall in to four categories: patient, doctor, environment and guideline.
In 2015 the Canterbury District Health Board changed to a new platform of online clinical guidance called Hospital HealthPathways. This platform differed significantly from its predecessor The Blue Book in both the development process and design of the clinical guidance. This study compared the use of and compliance with guideline recommendations between these two different platforms of clinical guidance. By doing so, this study was able to examine how guideline use and compliance is affected by the development process and design of a clinical guideline. Sub-group analysis examined how compliance varied between different clinicians, different patients, and different environments and also the interaction between these factors and guideline design.
A sub-analysis examined barriers to guideline compliance reported by clinicians to understand the perceived obstacles clinicians had to following guideline recommendations.
Finally, this study developed the concept of “appropriate non-compliance” by quantifying and describing cases where it was appropriate for clinicians not to follow local clinical guideline recommendations whilst managing patients.
This study adopted a mixed-methods methodology. Three conditions were selected for study: community acquired pneumonia (CAP), acute pancreatitis and intracranial haemorrhage (ICH) on warfarin. For each condition two distinct equivalent time periods were selected for comparison: the first when patients were managed by guidance in The Blue Book and the second when patients were managed by guidance in Hospital HealthPathways.
The use of the clinical guideline website was assessed by analysing unique page views of the guidance pages using Google Analytics. Compliance with guideline recommendations was assessed by a retrospective audit of the clinical notes. A survey was developed and sent to all hospital doctors to understand barriers to compliance. The concept of appropriate non-compliance was explored by documenting, quantifying and categorising reasons for non-compliance with clinical guideline recommendations documented in the clinical notes.
This study found that a change in the guideline development process and design not only improved use and compliance but also reduced the variation in practice between doctors. Presence of co-morbidity and severity of illness, were significant factors contributing towards non-compliance.
Clinicians agreed that clinical guideline recommendations do not apply to all patients. This study documented and quantified cases where following a guideline recommendation was not appropriate.
Patient factors, including co-morbidities and severity of illness, were significant factors contributing to non-compliance. However, a change in the guideline development and presentation not only improved use and compliance but also reduced the variation in practice between doctors. Previous research has suggested that usability can improve compliance but this study is the first to show how a modified platform can improve compliance and reduce clinician-related variation.
Non-compliance with guidelines is, at times, appropriate. The rate of appropriate non-compliance can be quantified.||