Psychiatric Bulletin (2002) 26: 421-424. doi: 10.1192/pb.26.11.421
© 2002 The Royal College of Psychiatrists
Psychiatric Bulletin (2002) 26: 421-424
© 2002 The Royal College of Psychiatrists
Attitudes of psychiatrists to evidence-based guidelines
A questionnaire survey
Harvey Rees, Consultant Psychiatrist,
Attila Sipos, Lecturer in Psychiatry,
Matthew Spence, Research Associate and
Glynn Harrison, Head of Division of Psychiatry
CABOT Mental Health Services, 12 Grove Road, Redland, Bristol BS6
6UJ
Declaration of interest
None.
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Abstract
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AIMS AND METHOD
We aimed to survey clinicians' attitudes on using evidence-based
guidelines. A postal questionnaire based on a previous survey of general
practitioners was sent to 105 psychiatrists working within Avon and Western
Wiltshire Mental Health Partnership NHS Trust.
RESULTS
There was a 91% response rate. Respondents were generally in favour of
clinical guidelines, with scores indicating a positive attitude to guidelines
in 13 of the 18 statements. The majority felt that guidelines were effective
in improving patient care, could be used flexibly to suit individual patients
and did not impinge on their clinical judgement.
CLINICAL IMPLICATIONS
Psychiatrists welcomed the increasing use of guidelines. Further research
is needed to determine whether this will translate into actual use and
improved outcomes for patients.
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Introduction
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Evidence-based guidelines (EBGs) are used increasingly in routine clinical
practice but in comparison with general practice, they are uncommon in
psychiatry. With the advent of the National Institute for Clinical Excellence
(NICE), the use of guidelines is likely to become more widespread as more
reviews are disseminated, but little is known about attitudes of psychiatrists
to their use.
Guidelines primarily aim to make care more consistent and efficient and
reduce inappropriate variations in practice. Clinical practice guidelines can
be defined as ‘systematically developed statements to assist
practitioner and patient decisions about appropriate health care for specific
clinical circumstances’ (Institute of
Medicine, 1992). EBGs are a specific adaptation based on critical
appraisal of scientific evidence and they clarify which interventions are of
proven benefit and document the quality of the supporting data
(Woolf et al, 1999).
The EBG development process should be explicit, clearly stating how evidence
was identified and selected. The development group should be representative of
all those to whom the EBGs will be relevant. Peer review should be included
and a review date explicitly stated in the guideline
(Marriott & Palmer,
1998).
Psychiatrists' attitudes to evidence-based psychiatry have been studied by
Carey & Hall (1999):
clinicians overwhelmingly (>90%) felt it was ‘useful’ in
clinical practice, but a similar number felt this to be true of clinical
intuition and the opinion of colleagues. Only 60% felt more use of
evidence-based practice was attainable. Watkins et al
(1999) explored how general
practitioners (GPs) gain access to and use guidelines. They concluded
guidelines were perceived as a useful method of accessing specialist
information; positive attitudes towards them were more common among younger
GPs. Siriwardena (1995) found
that GPs were generally in favour of clinical guidelines and believed them
effective in improving patient care. A positive response was associated with
GPs who had previously contributed to inhouse guidelines or participated in
audit. Our study examined psychiatrists' attitudes to EBGs and made
comparisons with previous research in primary care. It was hypothesised that
psychiatrists who qualified more recently (less than 8 years since
qualification to reflect the ‘era’ of evidence-based medicine)
would have more positive attitudes owing to more training in evidence-based
medicine and familiarity with guidelines.
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Method
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A postal questionnaire was sent to psychiatrists (consultant, specialist
registrar and non-consultant career grades listed as working in general adult
speciality; n=105) in one large specialist mental health care trust
(Avon and Western Wiltshire Mental Health Partnership NHS Trust; population
served 1.2 million). A second copy of the questionnaire was sent to
non-respondents after 6 weeks and followed up with a telephone reminder if not
returned subsequently. The characteristics of respondents can be seen in
Table 1.
The questionnaire consisted of 18 attitude statements on clinical
guidelines adapted from a questionnaire used to assess attitudes to guidelines
in general practice (Siriwardena,
1995). The original was developed following a qualitative pilot
study (literature search and semi-structured interviews with GPs), which
identified 10 ‘areas of concern’ as being relevant to the use of
guidelines. Statements particularly related to primary care (e.g.
performance-related pay) were replaced by alternatives (e.g. how guidelines
relate to research). Siriwardena surveyed 213 GPs whose mean statement scores
were used as a comparison group for the purpose of our study. As respondents
are more likely to reply in the affirmative, we employed a balanced
questionnaire using (randomly ordered) paired statements expressing opposite
attitudes. These are listed by category in
Table 2. A Likert-type scale
was used, with five response codes ranging from strongly agree (1) to strongly
disagree (5) for each statement. For analysis, scores were combined for
agreement (1+2) and disagreement (4+5). Mean scores were calculated after
reversing the scores for positive statements; thus a higher score always
signified a more positive attitude to guidelines. Mean scores for paired
statements in each category were added; a score of more than 6.0 indicated a
positive attitude, less than 6.0 indicated a negative attitude and 6.0
indicated equivocation. Completed questionnaires were analysed using SPSS for
Windows, Version 8.0 (SPSS,
1997).
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Results
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Of the 105 questionnaires sent to psychiatrists, 96 were returned completed
— a 91% response rate. The characteristics of respondents are shown in
Table 1. The mean years of
psychiatric experience was 12.7 (s.d. ± 7.2). The responses to the 18
attitude statements are displayed in pairs in
Table 2. Response scores
indicated a positive attitude to guidelines in 13 of the 18 statements, a
negative attitude in 1 and equivocation in 4. The majority (82.3%) believed
that guidelines were effective in improving patient care. There was also
strong agreement that clinical judgement could be exercised within guidelines
(85.7%), guidelines could be used flexibly to suit the needs of individual
patients (85.7%) and respondents found guidelines helpful to follow (70%).
There were trends for psychiatrists to be more positive than GPs in all these
areas (82% v. 69%, 85% v. 76%, 85% v. 74% and 70%
v. 57%, respectively) (see Fig.
1; GP percentage scores and means, from
Siriwardena, 1995). More
recently-qualified psychiatrists did not exhibit significantly more favourable
attitudes on any statements, and further subgroup analysis (on variables
gender, specialty and grade) revealed no significant differences. The two main
categories in which GPs scored more positively than psychiatrists were
believing guidelines were helpful to avoid litigation and that guidelines
should be sensitive to local needs.
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Discussion
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The excellent response rate (91%) indicates that our sample is highly
representative of psychiatrists within the trust. The study was not
sufficiently powered (small sample size) to detect any relevant differences
between psychiatrist groups. The results suggest psychiatrists have positive
attitudes towards EBGs and in most categories appear more favourably disposed
to them than GPs. However, Siriwardena surveyed a population in a different
region over 5 years previously. His survey did not discriminate between
locally-developed guidelines (often ‘owned’ by those involved in
development) and expert, systematically-based guidelines (potentially viewed
as imposition). Similarly, our questionnaire did not include a definition for
EBGs or examine how guidelines are formulated. The culture of using guidelines
in psychiatry and primary care is also likely to be different, with
psychiatrists having limited personal use compared with their GP colleagues.
Positive views from psychiatrists may, therefore, reflect an acceptance viewed
from a distance rather than from proven experience. Only 57% of GPs agreed it
was helpful to follow guidelines and the overall category score
(‘helpful to my own clinical practice’) was equivocal.
The increasing profile of guidelines within psychiatry is likely to be
controversial. The future demonstration of clinical competence as part of the
revalidation process (which the clinician may have to prove) could include
examination of how an individual's practice conforms to established
guidelines. Our results suggest psychiatrists will not see EBGs as a threat, a
majority believing they can improve patient care and retain flexibility for
individual patients while not diminishing clinical freedom. However, a
significant proportion (43%) remained concerned about ‘cookbook’
psychiatry arising from the widespread introduction of EBGs, which may be a
barrier to their clinical use. It will be important to harness favourable
attitudes to encourage psychiatrists to develop EBGs through evidence-based
approaches and local clinical audit. (GPs clearly support guidelines being
sensitive to the needs of local practice.) Within psychiatry, critics of EBGs
often state that there is insufficient evidence on treatment efficacy upon
which to develop valid guidelines. In this survey, 73% of psychiatrists
disagree.
In primary care, GPs frequently fail to follow systematic guidelines
(Moher & Johnson, 1994) and
there are notable failures in their impact on patient treatment outcomes
(Thompson et al,
2000). In spite of positive attitudes, there is no reason to
expect better results in psychiatry. The challenge for researchers will be to
demonstrate successful implementation strategies (of which EBGs will be only
one component of multifaceted interventions) that have clear efficacy in
treatment outcomes and which retain the favourable attitudes of those who use
them.
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Acknowledgments
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We thank all the psychiatrists who participated.
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References
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CAREY, S. & HALL, D. (1999) Psychiatrists' views
of evidence-based practice. Psychiatric Bulletin,
23,
159
-161.[Abstract/Free Full Text]
INSTITUTE OF MEDICINE (1992) Guidelines for
Clinical Practice. From Development to Use (eds M. Field & K.
Lohr). Washington, DC: National Academy Press.
MARRIOTT, S. & PALMER, C. (1998) Using clinical
guidelines. Advances in Psychiatric Treatment,
4, 25-30.
MOHER, M. & JOHNSON, N. (1994) Use of aspirin by
general practitioners in suspected acute myocardial infarction.
BMJ, 308,
760
.[Free Full Text]
SPSS (1997) SPSS 8.0 for
Windows. Chicago, IL: SPSS.
SIRIWARDENA, A. (1995) Clinical guidelines in primary
care: a survey of general practitioners' attitudes and behaviour.
British Journal of General Practice,
45,
643
-647.
THOMPSON, C., KINMONTH, A., STEVENS, L., et al
(2000) Effects of a clinical-practice guideline and
practice-based education on detection and outcome of depression in primary
care: Hampshire Depression Project randomised controlled trial.
Lancet, 355,
185
-191.[CrossRef][Medline]
WATKINS, C., HARVEY, I., LANGLEY, C., et al
(1999) General practitioners' use of guidelines in the
consultation and their attitudes to them. British Journal of
General Practice, 49,
11
-15.
WOOLF, S., GROL, R., HUTCHINSON, A., et al
(1999) Potential benefits, limitations, and harms of clinical
guidelines. BMJ, 318,
527
-530.[Free Full Text]
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Abstract
Introduction
