Chest
Volume 117, Issue 2, Supplement, February 2000, Pages 38S-41S
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How Can the Implementation of Guidelines Be Improved?

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Guidelines for a variety of diseases have now been produced. However, implementation of guidelines requires that the medical profession is willing to conform to patterns of diagnostic and treatment behavior set down by others. This may not happen in practice. Early experience in the United Kingdom was gained with the introduction of guidelines for the management of asthma. For a number of years, there have been improvements in practice, but deficiencies still exist. When the introduction of guidelines for the management of COPD was planned, a new approach was taken with a consortium of the British Thoracic Society, pharmaceutical companies, and medical equipment companies being formed to promote their use. Early studies show that COPD care starts from an even lower baseline than asthma; there is poor understanding of objective diagnosis of COPD in both primary and secondary care.

Section snippets

Experience With the British Thoracic Society Asthma Guidelines

At the time the asthma guidelines were being written, no one knew whether the recommendations were theoretical ideals or achievable practice. More important, there were no data to indicate whether the recommendations being preached in the guidelines were being practiced in our own clinical roles. The British Thoracic Society (BTS), together with the National Asthma Campaign and the Royal College of Physicians, performed a study in 36 hospitals looking at the process of acute asthma management

Implementation of the BTS COPD Guidelines

When guidelines for COPD were being produced in the United Kingdom in 1995 (published in 1997),5 the BTS was concerned about how best to promulgate the guidelines so that change would hopefully occur more rapidly than for asthma. As with most professional organizations, the BTS has little in the way of resources, and thus a consortium of eight pharmaceutical companies and six medical equipment companies and the BTS was formed. In the first year, copies of the guidelines were distributed to all

The Importance of Accurate Diagnosis

These two studies show how far actual practice is from that recommended in the guidelines. If the diagnosis is not made objectively, then what is the chance of appropriate management? Within the last 2 years, I have seen many cases of mistaken diagnosis leading to erroneous treatment. A description of three real examples follows:

  • A man of 56 years was referred because he wished to be offered early retirement on the grounds that his emphysema was preventing him from working in a moderately

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    Although Stempel et al11 investigated prescription patterns for 2 months after an ED visit and demonstrated that the increase in prescriptions for inhaled corticosteroids after an ED visit reverted to baseline rates in the second month after the index visit, we demonstrate that prescriptions rates remain low for at least a year after the visit. Possible reasons for this include failure of many patients to follow up after an ED visit, lack of physician familiarity with the guidelines, lack of agreement with guidelines, complexity of the guidelines, and failure to apply them correctly.25-33 Although a visit to the ED represents a failure of the NAEPP EPR-2 goals, it also represents an opportunity to improve asthma care.

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