Background
Methods
Participant and focus group procedures
Gender | |
Male | 9 |
Female | 16 |
Age | |
< 30 | 7 |
30–40 | 12 |
> 40 | 6 |
Clinical qualifications | |
Board certified | 10 |
Non-board certified | 8 |
Under residency training | 7 |
Type of practices | |
General practice | 8 |
General practice and faculty in residency program (post-graduate) | 4 |
General practice and faculty in College of medicine (under-graduate) | 6 |
General practice and under-training in residency program | 7 |
Years in practice | |
< 5 | 7 |
5–10 | 8 |
10–15 | 4 |
> 15 | 6 |
Results
Theme | Statements |
---|---|
Positive attitude towards guidelines | |
Provide evidence-based recommendation | ‘Most known guidelines contain summary of all studies and analyses; so I do not have to go through information in parts’ ‘Because it is supported by evidence from many trials and medications’. ‘Recommendations are based on trials that prove its effectiveness; this is more beneficial than the non-trial ones. It is a logical approach’ |
Cost-effective | ‘It’s cost-effective because it is the best care given’ |
Save time | ‘I think we need less time if we know the investigations to be done. It will not take time’ ‘Save time, more comfortable, more convenient. If the physician is aware of the guidelines, it will not take time’ |
Standardize care | ‘It is to standardize the language we speak and health requirements. Like any other business, it is measurable’ ‘More suited to patient’ ‘Trackable care’ ‘Measurable care’ |
Negative attitude towards guidelines | |
Changing evidence | ‘The CPG will be behind new studies by six months to 1 year; so we can’t think that it represents the latest evidence’ |
Contradicting recommendations | ‘There are some differences from American associations and others. Some say that HBA1c is a diagnostic test; others say it is a follow-up test’ |
Lack of ability of the doctors to read EBM | ‘You cannot be sure unless you learn how to access the paper and decide whether it is weak or strong. At the same time, there should be guidance from the organizing body on how to work around gaps; there should be some reference for people to go to. As an academic, this what I say but as a physician it is not practical; even the ones who know how to analyse an article, do they actually do it? I don’t think so’ |
Not applicable to each individual patient | ‘Individualized treatment. Guidelines don’t fit each individual’ ‘We can take the basic things and the rest can be tailored for each patient. Not every patient has the same case and same treatment’ |
Multiple sources | ‘Which guideline should you follow? Take this one or that? The British, American, or European’ |
Transferability of guidelines to local setting | ‘All adapted’ ‘Because we don’t have another option’ ‘We think it is true for particular circumstances, for that culture’ |
Attitude towards EBM and CPGs
Adapting CPGs
Theme | Quotes from participants |
---|---|
Sources of CPG used | ‘Most famous, trustable, acceptable by the community or you as a reader’ ‘Mostly updated’ ‘Applicable to patient’ ‘Should be from recognized body; not from just anywhere’ ‘No drug company involvement’ ‘Be government-funded’ ‘Should answer queries’ ‘Origin of guideline’ ‘Supported by organization’ ‘It depends on how the guidelines present the information’ |
Different culture and patients’ population | ‘I will take the guidelines because it is updated but in my opinion, patients differ here from the UK and USA’ ‘Adapted guidelines are trustworthy and I will not hesitate to choose [them]’ ‘We think it is true for particular circumstances, culture, and politics. We have to modify and produce our own practice [guidelines] and we have to conduct research’ ‘We are using it because we don’t have another option’ ‘It is successful [but] we cannot copy and paste all the time. We need information from our community and the problems we are facing’ ‘You can take what you need, and you can be selective according to the community and patients’ beliefs’ |
The ability to be selective and use the best knowledge from different CPGs | ‘[You can] combine more than one guideline to find all information needed’ ‘The volume of information is more in the original [guidelines]; local guidelines include only the useful information and applicable ones’ ‘It is easier, as the American Diabetic Association contains all the details and as a family physician I don’t need all that information; it is useful to know but it is too detailed’ |
Being endorsed by the institution | ‘Our guidelines adopt the most recent guidelines’ ‘Adapted guidelines have the power of authority of the local organization’ |
Perceived risk | ‘Risk, there should be standards or rule to follow any miss- phrasing can lead to wrong information’, ‘Should be ethical and mention the source’, “Not biased to any area, experience or need, we should mention all drugs and institution should follow recommendation”, “Self breast exam is harm but it is still in the national program and I am not following”, “We have to raise it up, they have something in their mind”, “We don’t know who is putting it, the things that supposed to be removed should be referred by special person whom we don’t know”, “We don’t know the methodology, partially we are not relying on the organization guidelines and in other parts where we are sure they are true we are relying on them” |
Guideline representation | ‘Customize the international guidelines to become national guidelines’ ‘Easier’, ‘Shorter’, ‘Relevant parts only’, ‘Simple’, ‘Easy language’, ‘Practical effective parts’ |
Sources of CPG
CPGs’ barriers and facilitators
Condition-related | Patient preferences | Medication or prescribing related | Test or test ordering related | Lack of continuity of care | Doctors knowledge or experience | Insurance related | Lack of structured care | CPG recommendation | Doctors’ perceived feasibility | Time factors | |
---|---|---|---|---|---|---|---|---|---|---|---|
OGTT as screening test for pregnancy | • | • | • | • | |||||||
Prescribing lipid lowering agents | • | • | • | • | • | • | • | • | |||
Action plan for asthma | • | • | • | • | • | • | |||||
Osteoporosis screening | • | • | • | • | • | ||||||
Self breast exam | • | • | |||||||||
Nephropathy screening in diabetes | • | • | • | • | |||||||
Aspirin use in diabetes | • | • | • |
Themes | Quotes on perceived effective implementation strategies |
---|---|
Barriers | |
Insurance coverage of services | ‘Insurance does not cover the drug’ |
Competition of private sector | ‘Continuity of care, the private clinics does not have guidelines’ |
Patient-related | ‘Patients’ acceptance’ ‘They don’t like to break their fast on Ramadan days’ ‘The taste of the oral solution’ ‘A lot reject the test’/‘They vomit’ ‘1 in 4 will accept’ |
Doctor-related | ‘Patients are not coming’ ‘Asthma action plan is devised by the chest physician’ ‘It (asthma action plan) will take time from doctors’ ‘Doctors believe and practice’ ‘Doctors are interested; we are checking the KPI and commenting on how to improve the practice’ |
Communication between hospitals and AHS | ‘It is followed in the hospital’ |
Lack of structured care for some conditions (e.g., asthma and osteoporosis) compared to widely implemented structured care for diabetes and hypertension in the AHS | ‘You have to choose the ones who are interested. You should not choose all. Doctors who don’t care shouldn’t be in the institution’ ‘Most have their spirometer but some clinics don’t’ ‘Accessing the whole organization and not individuals’ ‘It differs if you have a chronic disease care clinic. Doctors will be under pressure by other patients and will not give good care, and some doctors don’t have a sense of responsibility’ ‘There are no guidelines for osteoporosis’ ‘No, it is not like diabetes mellitus (DM); there are no guidelines and no special clinics’ ‘We are not following our target patients (osteoporosis patients)’ ‘It is a mistake of the institutions to not recommended screening for adults’ ‘Having well women clinics is better than having GP clinics’ |
Condition-related | ‘There is a higher prevalence of DM, complications, and diagnosis’, ‘easier to diagnose DM’, ‘all age groups have DM’ |
Facilitators | |
Accessibility of knowledge in the office | ‘Makes things easier; so, if you have any questions you have the answer easily’ ‘It reduces the anxiety of feeling alone, especially during out-of-hours clinics’ ‘Calculators are available in computers and programmes’ |
Quality monitoring | ‘Auditing’ ‘Institutional KPI’ ‘Patient satisfaction KPI’ ‘Guidelines improve their KPI; it should support the KPI or targets’, ‘They are seeking the KPI level four times per year’ ‘Other types of auditing, which we don’t know about in hospitals, like how our care affects admissions, complicated patients, and compliance’ ‘Yes, now they are trying their best to better achieve the KPI’ ‘To reach the KPI and help patients’ |
Endorsement from the institution | ‘They formulated guidelines but didn’t work to improve implementation of guidelines…it is individual work’ ‘If the guidelines are available in the institution, it is the responsibility of all to follow it because we all care for the same patients and we should speak the same language with the patient’ ‘About breast cancer screening; it is a national programme. They didn’t give the option to do it or not. So, we are applying it and until they change it I have to follow it as it is supported by the organization’ ‘We cannot follow the institution always; this depends on the situation because if what is recommended by the institution is wrong we might miss-practice and put the patient at risk’ ‘As long as the guidelines are issued by the organization it is more likely to be followed and more likely that they have something in their mind; we are not aware of all statistics they have. They have all statistics and information, and as long as it is not harmful we follow them’ ‘The HAAD and SEHA are looking for quality now’ |
Electronic medical records | ‘It is difficult with paper medical records and needs staff’ ‘Introduction to m-pages (health maintenance reminder page) is one way of helping people to follow the guidelines’ ‘If it used, it is effective’, ‘guidelines link to medical records’ |
Structured care | ‘It differs if you have a Chronic Diseases Clinic from if you don’t, and doctor will be pushed by other patients and will not provide good care. Some doctors don’t have a sense of responsibility’ ‘If not, Chronic Diseases Clinic performance will be the same? I don’t think [so] at all’ ‘If I was a GP and a chronic disease patient visited me, I will not be able to attend to him well, because many more patients will be waiting outside’ |