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dc.contributor.advisorArdagh, Michael
dc.contributor.advisorFrizzelle, Frank
dc.contributor.authorCooper Maidlow, Serin
dc.date.available2019-11-11T01:55:09Z
dc.date.copyright2019
dc.identifier.citationCooper Maidlow, S. (2019). Clinical guideline use and compliance: examining variation from the clinical pathway (Thesis, Master of Medical Science). University of Otago. Retrieved from http://hdl.handle.net/10523/9786en
dc.identifier.urihttp://hdl.handle.net/10523/9786
dc.description.abstractIntroduction Clinical guidelines are developed with the aim of optimising patient care and have been shown to improve both clinical outcomes and the care process. ‘Hospital HealthPathways’ are guidelines published for use within Canterbury District Health Board (CDHB) hospitals. Previous research into guideline use and compliance in CDHB coined the term ‘appropriate non-compliance’, describing clinically appropriate variation from guideline recommendations. This study used a prospective methodology to observe access of and compliance with the Hospital HealthPathways Community Acquired Pneumonia (CAP) guideline and explore reasons for not accessing or not complying with the guideline. Cases of ‘appropriate non-compliance’ were identified, and a target rate of compliance quantified, taking this into account. Based on findings from the previous research, ‘Practice Points’ – bullet points for emphasis and clarity – were added to acute pancreatitis and CAP guidelines. This study also evaluated the effect of these Practice Points. Findings from the study suggested that the purpose behind a guideline recommendation might influence compliance. A survey was performed to investigate this possibility. Method Demographic data, and data regarding compliance with five key CAP guideline recommendations was collected. Doctors were interviewed regarding their access of and compliance with the guideline. Logistic regression was used to perform subgroup analysis. Demographic data, and data regarding compliance with a ‘Practice Point’ added to the acute pancreatitis guideline was obtained for comparison with data from the previous CDHB research. A survey was designed using a modified three-round Delphi technique to investigate how often doctors thought they should comply with recommendations made for a variety of different reasons, and the comparative importance they placed on the reasons behind the recommendations. Results Usage of the CAP guideline was 38%. Doctors stated they did not access the guideline because they had already made management plans or because they disagreed with the guideline. Both patient and doctor related factors were shown to affect whether guidelines were accessed. Doctor related factors were also shown to affect the reasons for not accessing the guideline. Compliance with four of the guideline recommendations ranged between 67.5-73.5%, however compliance with the recommendation regarding antibiotic choice was lower at 47.5%, leading to poor overall guideline compliance (21.2%). Most doctors did not follow the antibiotic recommendation for objective reasons. Patient and doctor related factors were shown to affect overall guideline compliance. Doctor related factors were also shown to affect the reasons for non-compliance. The target rate of compliance with the antibiotic recommendation, taking into account appropriate non-compliance, was quantified as 62-72%. A significant increase in compliance of 13% was observed with both acute pancreatitis and CAP guideline recommendations following the addition of the Practice Points. In the final round of the survey, a recommendation made for the purpose of preventing short term adverse effects on patients was rated most important. Conclusion The results of this study illustrate the complexity of influences on guideline compliance. The many and varied examples of appropriate non-compliance reflect the case-by-case reprioritisation of the facets of patient care by clinicians, despite the continued proliferation of clinical guidance. Studies such as this can enhance understanding of how doctors use clinical judgement to respond to scenarios they feel outlie the guidelines. Improving guidelines to better reflect how they are used by clinicians could in turn increase guideline compliance.
dc.format.mimetypeapplication/pdf
dc.language.isoen
dc.publisherUniversity of Otago
dc.rightsAll items in OUR Archive are provided for private study and research purposes and are protected by copyright with all rights reserved unless otherwise indicated.
dc.subjectClinical Guidelines
dc.subjectClinical Practice Guidelines
dc.subjectChristchurch Hospital
dc.subjectChristchurch Public Hospital
dc.subjectAntibiotic stewardship
dc.subjectCommunity Acquired Pneumonia
dc.subjectPneumonia
dc.subjectChoosing Wisely
dc.subjectPancreatitis
dc.subjectAcute Pancreatitis
dc.subjectCompliance
dc.subjectIntentional Non-adherence
dc.subjectAppropriate Non-Compliance
dc.subjectPractice Point
dc.subjectHospital HealthPathways
dc.subjectHealthPathways
dc.subjectCanterbury District Health Board
dc.titleClinical guideline use and compliance: examining variation from the clinical pathway
dc.typeThesis
dc.date.updated2019-11-11T01:25:06Z
dc.language.rfc3066en
thesis.degree.disciplineSurgery
thesis.degree.nameMaster of Medical Science
thesis.degree.grantorUniversity of Otago
thesis.degree.levelMasters
otago.openaccessOpen
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