Mant et al are not the first to point out that patients in primary
care are unlike those recruited to clinical trials.1 Neither was it
surprising that almost two thirds of patients were not managed according
to published guidelines. However it might be a mistake to assume that one
is a consequence of the other. It is questionable whether the publication
of yet more rigorously tested and evidence-based guidelines would be more
enthusiastically implemented.
General practitioners in South Yorkshire
reviewed their clinical practice and published their findings.2 They
suggest that even in the most committed practices the application of
guidelines is a function of the patient’s knowledge, the amount of ‘noise’
in the consultation and the general practitioner’s determination to apply
guidelines. In the last decade UK primary care has been offered
incentives, target payments, to take a public health approach. Patients on
the other hand steadfastly refuse to accept a reductionist view of their
needs. There are many and complex reasons why a patient may not seek a
prescription, referral or any other intervention and a different set of
reasons why their general practitioner might not offer one. It is this
research that might help to ‘target’ the ‘right’ patients arguably more
than yet another epidemiological study. The latter is challenging, the
former requires imaginative designs to explore in detail behaviour that is
difficult to observe in practice and will be strongly influenced by the
local context in which health care is delivered.
References
1. Mant J, McManus RJ, Hare H. Applicability to primary care of
national clinical guidelines on blood pressure lowering for people with
stroke: cross sectional study. BMJ 2006;332: 635-7.
2. Jiwa M, Freeman J, Fisher C, Schrecker G, Gordon M, Reid J. Factors
that impact on the application of guidelines in general practice: A review
of medical records and structured investigation of clinical incidents in
hypertension. Quality in primary care. 2005,13:215-22
Competing interests:
None declared
Competing interests:
No competing interests
28 March 2006
Moyez Jiwa
Associate Professor
General practice,University of Western Australia, WA 6010
Rapid Response:
More research or different research?
Mant et al are not the first to point out that patients in primary
care are unlike those recruited to clinical trials.1 Neither was it
surprising that almost two thirds of patients were not managed according
to published guidelines. However it might be a mistake to assume that one
is a consequence of the other. It is questionable whether the publication
of yet more rigorously tested and evidence-based guidelines would be more
enthusiastically implemented.
General practitioners in South Yorkshire
reviewed their clinical practice and published their findings.2 They
suggest that even in the most committed practices the application of
guidelines is a function of the patient’s knowledge, the amount of ‘noise’
in the consultation and the general practitioner’s determination to apply
guidelines. In the last decade UK primary care has been offered
incentives, target payments, to take a public health approach. Patients on
the other hand steadfastly refuse to accept a reductionist view of their
needs. There are many and complex reasons why a patient may not seek a
prescription, referral or any other intervention and a different set of
reasons why their general practitioner might not offer one. It is this
research that might help to ‘target’ the ‘right’ patients arguably more
than yet another epidemiological study. The latter is challenging, the
former requires imaginative designs to explore in detail behaviour that is
difficult to observe in practice and will be strongly influenced by the
local context in which health care is delivered.
References
1. Mant J, McManus RJ, Hare H. Applicability to primary care of
national clinical guidelines on blood pressure lowering for people with
stroke: cross sectional study. BMJ 2006;332: 635-7.
2. Jiwa M, Freeman J, Fisher C, Schrecker G, Gordon M, Reid J. Factors
that impact on the application of guidelines in general practice: A review
of medical records and structured investigation of clinical incidents in
hypertension. Quality in primary care. 2005,13:215-22
Competing interests:
None declared
Competing interests: No competing interests