Bridging the gap between guidelines and clinical practice an educational intervention in primary care

Abstract

The aim of this study was to develop a new kind of information programme to be provided by community pharmacists to groups of doctors at community health centres in Sweden, and to test the effectiveness of this programme in improving the primary care doctors' clinical performance. A randomised controlled trial was carried out within the primary health care system in Sweden in order to assess the impact on clinical practice in the intervention group compared with doctors in the control group who only received regular written information material. Management of hyperlipidaemia (hypercholesterolaemia) was chosen as the specific target for the intervention programme. One hundred and thirty-four community health centres from 13 Swedish counties with in total 570 doctors, were matched in pairs, and the health centres in each pair were randomised into the intervention or the control group (randomisation by group).

The intervention comprised information on the management of hyperlipidaemia, derived from the national guidelines, and was conveyed by 37 specially educated community pharmacists, according to principles of 'academic detailing' and adult learning. lt was performed at four half-hour sessions with all doctors (3- 10) in each health centre, all within a period of six months. In addition interviews were conducted with a subsample of 20 doctors, and ethnographic fieldwork was performed at two health centres. In the evaluation of the effects, both quantitative and qualitative methods were used. Outcome measures were prescriptions of lipid-lowering drugs dispensed at the local pharmacies, and information on doctors' management of hypercholesterolaemic patients through a review of 2883 medical records (diagnostic investigations, non-pharmacological and pharmacological treatment). Changes of the doctors' conceptions regarding the treatment of hyperlipidaemia were also used as outcome measures. A survey of the doctors' attitudes was also completed. Statistically significant effects were found at the health centres in the intervention group on the choice of recommended drugs and on the appropriate management of hyperchole sterolaemic patients with additional risk factors for atherosclerotic cardiovascular disease. The role of pharmacists in facilitating doctors' learning was appreciated by a great majority of the doctors.

There were significant changes in the doctors' conceptions regarding management of hyperlipidaemia in the intervention group, but not in the control group, to become more in line with the treatment recommendations. The anthropological field-work disclosed the mechanisms in clinical practice that balance and complement the evidence based medical information or continuing education. The findings support the view that peer groups are an effective form of continuing medical education and that community pharmacists can act as facilitators in 'academic detailing' of national treatment guidelines. A multi- and interdisciplinary collaboration enables a fuller description and interpretation of the effects of an educational intervention.