Local clinical guidelines: description and evaluation of a participative method for their development and implementation.

BACKGROUND: National guidelines are rarely followed by immediate change in clinical behaviour. We present our experience of an active educational method for local development and implementation of a guideline. OBJECTIVE: To evaluate the effectiveness of a participative method for developing local clinical guidelines. METHODS: A trial in a district of the effect of guideline development incorporating active participation of intended recipients on subsequent relevant prescribing. It was carried out in Wirral Family Health Services Authority district (the Wirral peninsula) comprising 69 general practices covering a population of 345,763. An exemplar guideline on 'hypertension in the elderly' was developed by the method described. The principal recommended drug was bendrofluazide 2.5 mg once daily. The differences in prescribed daily doses (PDD) of bendrofluazide 2.5 mg tablets per quarter per 1000 prescribing units (age-weighted population) between the intervention district and England as a whole was measured. RESULTS: Comparison of the intervention district with England data demonstrates a median difference of 122.49 PDD before and 206.34 PDD after guideline production, this change is statistically highly significant (Mann-Whitney two-tailed P < 0.0001; 95% CI = 36.51-104.77). Grouped regression analysis shows no significant difference (0.89) in slope gradients before guideline production (P = 0.35, 95% CI = -3.97-5.76), but the difference in slope gradients after (12.95) is statistically highly significant (P < 0.0001; 95% CI = 8.17-17.73). The data suggests that the change in clinical behaviour persisted for at least two years. CONCLUSION: Participation of intended recipient general practitioners and local specialists in the development of a guideline by an active educational method as described was followed by a favourable change in clinical behaviour which persisted for at least two years.

Enzymatic and morphometric evidence for Crohn's disease as a diffuse lesion of the gastrointestinal tract.

Intestinal disaccharidase and dipeptidase activities were measured in mucosal biopsies from the proximal jejunum in 20 patients with Crohn's disease apparently confined to the distal ileum or large bowel, 14 patients with ulcerative colitis, and 14 healthy volunteers who acted as controls. The dissecting microscopy and histological appearance of the biopsies were normal (Gd 0-1) except for two which showed grade 2 changes. tbiopsy morphometry showed a reduction of jejunal mucosal surface area and an increase in mucosal volume in patients with Chron's disease when compared with the other two groups. The mucosal enzymes studies demonstrated that patients with Crohn's disease had a significant reduction in brush-border enzymes (disaccharidase) but no change in cytoplasmic enzyme activity (dipeptidases). The enzyme levels in patients with ulcerative colitis did not differ from the healthy controls. The reduction of brush-border enzymes with normal cytoplasmic enzymes in the presence of abnormal morphometry is further evidence of the concept of Crohn's disease as a diffuse lesion of the gastrointestinal tract. It also suggests that there is either specific damage to the microvilli or some other abnormality such as impairment of enzyme synthesis.