Applying clinical guidelines in general practice: a qualitative study of potential complications
Applying clinical guidelines in general practice: a qualitative study of potential complications
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DOI：
10.1186/s12875-016-0490-3
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发表时间：
2016-07-22
影响因子：
2.9
通讯作者：
Helvik, Anne-Sofie
中科院分区：
文献类型：
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作者：
Austad, Bjarne;Hetlevik, Irene;Helvik, Anne-Sofie
背景：单一疾病的临床指南经常在多病患者的全科实践工作中提出问题。然而，很少有研究关注遵循多种指导方针的需求对一般实践的影响。本研究探讨了挪威全科医生（gp）的经验和对应用多种指南的全科医生的后果的反思。方法：在挪威中部进行定性焦点小组研究。这项研究从四个已有的群体中抽取了25名挪威全科医生作为样本。访谈录音，转录和分析使用系统的文本浓缩，即应用现象学方法。结果：全科医生的反应集中在两大主题上：1)采用多种指南的全科医生的并发症；2)当全科医生采用多种指导方针时，患者的并发症。对于全科医生来说，应用多种指导方针会产生很大的问题，因为他们觉得有义务实施不适合他们病人的指导方针：地图和地形经常不匹配。他们承认，他们对自己的医疗实践也有更大的不安全感，这导致他们更倾向于实施“防御性医疗”。对于他们的病人来说，全科医生的经验是，采用多种指导方针会增加多药、过度的非药物建议、医学化倾向的风险，对一些人来说，还会降低生活质量。结论：全科医生在被迫对多种疾病患者应用多种单一疾病指南时，经历了负面后果，包括增加多种药物和过度治疗的风险。我们相信，以病人为中心的护理和全科医生在必要时不遵守规定的勇气可能有助于减少这些风险。卫生保健当局和指南的制定者需要意识到在多病非常普遍的全科实践中应用单一疾病重点的潜在负面影响。
Background: Clinical 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.Methods: Qualitative 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.Results: The 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.Conclusions: The 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.