Guidelines For Rti The Value of Guidelines

In general, clinical guidelines have been shown to improve medical practice (37). The use of clinical practice guidelines can be an effective means of changing

TABLE 1 Impact of Guideline Interventions on Antimicrobial Usage and Resistance

Study (reference) Country

Kristinsson et al. (29) Iceland

Seppala et al. (30) Finland

Guillenot et al. (34) France

Intervention Reduction in antibiotic use

Reduction in macrolide use for certain infections

Evaluation of antibiotic practice guidelines through computerassisted decision support

Provider and community education for prescribing antibiotics for RTIs in Alaska

Use of household and/or office-based patient educational materials as well as clinician detailing compared to controls

Educational interventions aimed at parents, physicians, and pharmacists designed to reduce antibiotic use for upper RTIs

Observations

Overall reduction in antibiotic use (penicillin from 20% to < 15%), associated with reduction of drug-resistant Streptococcus pneumoniae Resistance of Streptococcus pyogenes decreased from 19% to 9% Antibiotic use decreased by 22.8%, rate of antibiotic adverse events decreased by 30%, antibiotic resistance remained stable Education of healthcare providers and patients substantially decreased the number of visits and antimicrobial prescriptions for RTI, and the carriage of PRSP

Antibiotic prescription rates declined at sites implementing both use of office-based patient educational materials as well as clinician detailing Antibiotic sales fell 32-37% depending on the intervention. The rate of colonization with PRSP was seen in intervention groups

Abbreviations: RTI, respiratory tract infection; PRSP, penicillin-resistant Streptococcus pneumoniae.

behavior, such as promoting the appropriate use of antibiotics. Effective clinical guidelines should improve patient care while enhancing cost savings. However, cost savings should not be the primary motivating factor. A recent example reported by Beilby et al. described a government intervention in Australia intended to decrease costs by reducing the use of amoxicillin-clavulanate (38). As a result, costs increased through the occurrence of adverse outcomes in patients with acute otitis media (AOM), sinusitis, lower RTI, and acute exacerbations of chronic bronchitis (AECB).

To maximize effectiveness and applicability, antibiotic use guidelines should be evidence-based. The guidelines should also reflect data on resistance, recognizing that local patterns of resistance often differ across geographic regions. Hence, effective guidelines should be readily adaptable for implementation locally. Primary objectives of guidelines for treating RTIs should be to discourage antibiotic use to treat viral illness, to outline diagnostic criteria, and to avoid the use of ineffective antimicrobials.

Unfortunately, a meta-analysis of relevant studies has shown that there are numerous barriers to adherence to practice guidelines (Table 2) (39). For example,

TABLE 2 Barriers to Clinician Adherence to Clinical Practice Guidelines

Barrier

Explanation

Lack of awareness Lack of familiarity Lack of agreement

Lack of self-efficacy Lack of outcome expectancy Lack of motivation Guideline-related barriers Patient-related barriers

Environmental-related barriers

Clinician unaware that the guidelines exist Clinician aware of guidelines but unfamiliar with specifics Clinician does not agree with a specific recommendation made in guideline or is averse to the concept of guidelines in general

Clinician doubts whether he/she can perform the behavior Clinician believes the recommendations will be unsuccessful Clinician is unable/unmotivated to change previous practices Guidelines are not easy or convenient to use Clinician may be unable to reconcile guidelines with patient preferences Clinician may not have control over some changes (e.g., time, resources, organizational constraints)

Source: Adapted from Ref. 39.

clinicians may not be aware of all of the available guidelines or may not be well versed in how to apply specific recommendations appropriately. In addition, clinicians may not agree with some or all of the recommendations made or, as a general principle, may resist the concept of guidelines. If clinicians are doubtful that they can perform the task called for in the guidelines or harbor a belief that the recommendations will be unsuccessful, they probably will not follow the guidelines. Time constraints or healthcare organization requirements may impose restrictions that hamper the clinician's ability to implement the guidelines. Furthermore, the clinician may not have control over some changes called for in guidelines, such as the acquisition of new resources to perform diagnostic tests. Patient preferences for alternatives not recommended in guidelines also may obstruct adherence to clinical practice guidelines. To be successful, educational efforts and interventions aimed at improving adherence to practice guidelines—such as use of checklists and reminder systems—should address all of the identified barriers.

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