BMJ 1998;316:509-513 (14 February)

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Guidelines on anticoagulant treatment in atrial fibrillation in Great Britain: variation in content and implications for treatment

Richard Thomson, senior lecturer in public health medicine,a Helen McElroy, research associate,a Mark Sudlow, MRC special training fellow in health services research b

a Department of Epidemiology and Public Health, School of Health Sciences, Medical School, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HH, b Departments of Epidemiology and Public Health and of Medicine, Medical School, University of Newcastle upon Tyne

Correspondence to: Dr Thomson Richard.Thomson@newcastle.ac.uk

Objective: To describe the content of guidelines on the use of anticoagulant treatment in patients with atrial fibrillation and the impact of variations in guidelines on treatment.
Design: Postal survey of guidelines, semistructured interview with lead developers of guidelines, and application of guidelines to patient sample.
Subjects: 15 lead developers of the 20 guidelines identified in the postal survey were interviewed. 100 patients over 65 with atrial fibrillation to whom the guidelines were applied.
Main outcome measures: Evaluation of guidelines and the methods of dissemination, implementation, review, and evaluation; proportion of patients recommended for anticoagulant treatment by each guideline; and level of agreement between guidelines.
Results: There was considerable variation in whether anticoagulant treatment was recommended for subjects (range 13% to 100%, {kappa}=0.12). Guidelines varied greatly in advice on treatment by age, the use of echocardiography, and the target value or range of the international normalised ratio (8 of the 20 guidelines included values unlikely to be effective). Development was unsystematic; evidence based approaches were rarely used. 9 of the 15 lead developers had developed the guidelines themselves, and the 6 guidelines developed by groups relied on informal consensus. Methods to support effective dissemination, implementation, and evaluation were limited.
Conclusion: The widespread non-systematic production of guidelines has led to considerable variation with implications for the quality of care and clinical decision making. There is a need for a central, well funded programme of guideline development to ensure that valid guidelines are produced and disseminated.

Key messages

  • Clinical practice guidelines improve the process and outcomes of health care, but these improvements are dependent on the validity of the advice the guidelines contain

  • A survey of guidelines in Great Britain for the use of anticoagulant treatment to prevent stroke in patients with atrial fibrillation showed variation in their content and in the processes of development, dissemination, implementation, and evaluation

  • Applying these guidelines produced variation in treatment

  • This variation is most likely to be caused by non-systematic methods of development, which implies that some guidelines advocate management strategies that are less than optimal

  • Such variation could have profound effects on the incidence of stroke and bleeding complications and would lead to substantial differences in the use of resources, particularly anticoagulation services


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