Clinical guidelines are evidence-based recommendations designed to guide decision making in healthcare. Compliance with guideline recommendations within clinical practice has been shown to streamline and coordinate processes of patient care.¹ A range of factors influence whether healthcare professionals use and comply with these guidelines.² The factor which is most open to intervention is the guideline itself.³ This study focuses on whether a simple alteration to clarify and highlight a key point in a clinical guideline increased compliance with the recommendation in question.

Many studies of different aspects of clinical guidelines and their utilisation have been carried out as guidelines continue to proliferate. Compliance with recommendations made within guidelines has often been shown to be poor.⁴ A range of reasons and solutions are put forward in the relevant literature. It has been shown (in the main via surveys of clinicians) that guidelines that are perceived to be easy to read are more likely to be followed; and that poorly accessible, complex or vague guidelines are less likely to be followed.^5–7 A study carried out in 2017 into factors affecting compliance with clinical guidelines within Canterbury District Health Board (CDHB—healthcare provider for the Canterbury region of New Zealand) showed that a change in the platform of clinical guidance (from online documents written by separate departments to Hospital HealthPathways—an interactive website of ‘pathways’ written and curated by a dedicated team) was associated with an increase in use and compliance by clinicians. In addition, it reduced the variation in practice among different types of clinician.³

Method

The clinical guideline chosen for intervention was a Hospital HealthPathways guideline for the investigation and management of acute pancreatitis (see Figure 1). Hospital HealthPathways is a web-based collection of guidelines consisting of recommendations on local best practice for the assessment and management of common medical conditions, written by a clinical editor and subject matter expert for use within CDHB.8

Figure 1: CDHB HealthPathways guidelines for acute pancreatitis, highlighting Practice Point and serum monitoring recommendation.

In CDHB, adults with acute pancreatitis may present to Christchurch Public Hospital or Ashburton Hospital. Christchurch Public Hospital is the largest tertiary, teaching and research hospital in the South Island of New Zealand, where patients with pancreatitis are managed by resident medical officers (RMOs) under the supervision of consultant general surgeons in the emergency department, surgical assessment and review area, and on surgical wards. Ashburton Hospital is a 74-bed secondary-level acute medical and surgical hospital, where patients are managed by RMOs and senior medical officers (SMOs) in an acute assessment unit or on a general ward.

The guideline recommended that measurement of serum amylase should be used to make a diagnosis of pancreatitis, and measurements of serum complete blood count, electrolytes, urea, creatinine and CRP should be used to monitor patient progress thereafter (see Figure 1).

Local expert opinion held that further measurements of serum amylase did not change management and therefore testing should be limited to a single diagnostic measurement of serum amylase. In May 2017, a ‘Practice Point’ (a highlighted bullet point) was added to the guideline, clarifying these recommendations by specifying that “amylase and lipase are useful for diagnosis only. Serial measurements are not useful to assess severity or monitor progress”.

No other changes in the format were made, and there was no change to the content of the guideline. Although subject matter experts involved in writing the clinical guidelines were notified by email when the Practice Point went live, no RMOs or other staff received any notification from the HealthPathways team. Between the two time periods, an electronic clerking and clinical notes system, Cortex, was introduced to the surgical wards in Christchurch Hospital. Cortex did not alter how tests are requested, but is largely accessed via iPads, offering RMOs an alternative, point-of-care platform from which it is possible to review patients’ test results and access HealthPathways guidelines (although during these time periods there was not a HealthPathways App or a specifically mobile device-friendly website).

Compliance with this recommendation lends itself to straightforward and clear data collection and analysis. Although in CDHB blood tests are requested using a paper-based ordering system, results are made available on the DHB’s online clinical information system. The number of amylase measurements requested for each patient was assessed using the CDHB’s online clinical information system. Based on the number of amylase measurements performed, initial investigation could be categorised as either compliant (one amylase result only) or non-compliant (any more than one amylase result).

A data set of patients from a six-month period between August 2016 and February 2017, collected for a previous study, was used with the author’s permission as a control group. This time period ended three months prior to the change in format of the guidelines.3 A new data set of patients from a six-month period between August 2017 and February 2018 formed the experimental group. This time period started three months after the change in guideline format. The time periods each included RMO training quarters 3, 4 and 1; during each six-month period, three separate cohorts of house officers and three separate cohorts of registrars rotated through the medical and surgical specialties.

Patients were identified by an information analyst from the CDHB’s Decision Support team using ICD-10-CM codes K85.0 to K85.9, which includes all diagnostic codes for acute and subacute pancreatitis.⁹ Patients were included if their discharge diagnosis was documented as acute pancreatitis or a subgroup of acute pancreatitis. Patients were excluded if they had chronic pancreatitis or known pancreatic malignancy; they were discharged with a different diagnosis; if their records were inaccessible; or if the diagnosis of pancreatitis was made using pancreatic lipase levels alone.

One researcher examined the admission dates and discharge summaries of the included patients, and subsequently accessed the corresponding laboratory results using the CDHB’s online clinical information system. The number of times amylase levels were measured during that admission was then recorded.

Results

Of an initial 203 patients, 11 (6%) were excluded as they had chronic pancreatitis or known pancreatic malignancy. Nine (4%) were excluded as acute pancreatitis was diagnosed on lipase measurement alone. One was excluded as the full records were not accessible.

Table 1: Compliance with guideline recommendations on amylase measurement before and after addition of Practice Point.

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*P value calculated using χ2.

Before the Practice Point was added to the guideline, 82 of 126 total patients (65%) had amylase measured only once, on admission, in compliance with the Hospital HealthPathway guideline. After the addition of the Practice Point, 142 of 182 patients (78%) had one measurement of amylase, illustrating a 13% increase in compliance between the two time periods. This is a significant finding (P=0.017, 95% confidence interval).

Of the 44 incidences of non-compliance before the Practice Point was added, 30 (24%) had two amylase measurements, eight (6%) had three measurements, three (2%) had four, two had five, and one had eight. After the addition of the ‘Practice Point’, 28 of the 40 incidences of non-compliance (15%) had two amylase measurements, 10 (6%) had three measurements, one had four, and one had five. Of the non-compliant incidents, the specific number of subsequent amylase measurements did not change significantly before and after the change in format (P=0.095–0.403, 95% confidence interval).

Table 2: Referral method and compliance with guideline recommendations on amylase measurement.

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*P value calculated using χ2.

When the route of referral is taken into account, the results demonstrate that the improvement in compliance following implementation of the Practice Point is seen in those patients who were referred directly by their GP to the general surgical teams and those few patients managed by other specialties (eg, rural medicine, gastroenterology, general medicine or healthcare of the elderly). The rate of compliance for patients initially assessed in the emergency department was actually shown to decrease slightly, although compliance in this group was already relatively good and the change was not statistically significant (p=0.546, 95% confidence interval).

Figure 2: Month-to-month compliance with guideline recommendations on amylase measurement three months following addition of Practice Point.

Compliance varies significantly over the six-month period in the experimental group, with the greatest variance observed in December (p=0.029, 95% confidence interval, calculated using test for equality of proportions). The start of the RMO training year at the end of November may have contributed to this, as newly qualified house officers may be less familiar with the guidelines. However, given the subsequent marked improvement seen in January, this interpretation should be accepted with caution. The month-to-month variation in compliance suggests neither a clear trend of improvement nor decay in knowledge. In a healthcare environment with high variability and low predictability, it is likely that the inconsistency of this change over time represents random variation, or the possible influence of variables beyond the scope of this study.

Discussion

These results show a significant increase in compliance with the guideline recommendation to avoid serial serum amylase measurements for patients with acute pancreatitis after this recommendation was made explicit. This supports the findings of current literature that clinicians are more likely to comply with clearer guidelines.^6,7 These results are also in line with the previous study examining compliance with Hospital HealthPathways in Christchurch Public Hospital, which noted that a change in how a clinical guideline is presented can lead to improved compliance with that guideline.³

Movements such as ‘Choosing Wisely’ (an initiative begun by the American Board of Internal Medicine) are advancing dialogue around avoiding unnecessary medical tests and treatments.¹⁰ As with any diagnostic test, reasons unnecessary measurements of serum amylase should be avoided are patient-centred (venepuncture can be associated with risks, eg, pain and site infection); financial (processing each sample costs $5.46); and clinical (more investigations increase the risk of encountering erroneous or false positive results).¹¹ If the average number of amylase measurements before adding the Practice Point had not changed, 54 more amylase measurements would have been taken over the six-month period following its addition.

Despite the continued publication of clinical guidelines based on empirical evidence, studies have tended to reflect a lack of compliance by healthcare professionals with these recommendations.⁴ These findings suggest that RMOs caring for these patients are both using and complying with the local hospital guidelines. The significant effect seen following this simple intervention has implications for guidelines developers seeking to maximise quality patient care. As the style and format of a clinical guideline is under the control of its author, changing these is an efficient way to affect levels of compliance with the guideline. Like Hospital HealthPathways, many clinical guidelines can now be accessed online, and therefore alterations can be made quickly and easily.¹² Other factors which have been found to affect compliance, such as characteristics of the doctor, patient and the setting in which guidelines are accessed and utilised are not so simple to alter.³ Closure of the audit loop via feedback to those clinicians with a front-line role in caring for patients has been shown previously by the same department to improve both compliance rates and outcomes.¹³ These measures together therefore have the potential to amplify the individual benefits of each, leading to even greater improvements.

Although overall compliance was increased after the addition of the Practice Point, incidences of non-compliance continued to occur, and ongoing improvement over time was not clearly shown. In order to improve compliance further, other measures (such as guideline review as part of departmental induction, or use of e-ordering with built in alerts) are likely to be necessary.

As this study design is retrospective and purely quantitative, reasons for non-compliance with the guidelines were not examined. The online clinical information system did not record information pertaining to who requested the amylase measurement, and therefore characteristics of the healthcare professionals involved were unavailable for comparison. There is also the potential for confounding factors such as different rotating junior staff or departmental education to have influenced the results.

The findings from this interventional study imply that how recommendations are written and presented within clinical guidelines affects how they are used. If applied judiciously, financial, clinical and patient-centred improvements could potentially be achieved as a result of one simple addition to the guideline.

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