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ORIGINAL ARTICLE
Year : 2019  |  Volume : 18  |  Issue : 1  |  Page : 47-50  

Standard treatment guidelines: Perception and utilization in a tertiary health care facility in South-South, Nigeria


Department of Medicine, Clinical Pharmacology and Therapeutics Unit, University of Benin Teaching Hospital; Department of Clinical Pharmacology and Therapeutics, University of Benin, Benin City, Edo State, Nigeria

Date of Web Publication5-Feb-2019

Correspondence Address:
Dr. A Stephen Ayinbuomwan
Department of Medicine, University of Benin Teaching Hospital, PMB 1111, Benin City, Edo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aam.aam_25_18

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   Abstract 


Background: The Nigerian National Standard Treatment Guidelines (NSTG) was introduced in 2008 and the second edition was launched in 2017. This study evaluated the level of awareness, acceptance, and use of this tool within the Nigerian health-care system. Methodology: This study was carried out at the University of Benin Teaching Hospital, Benin City, Nigeria. A semistructured questionnaire was administered to doctors in the hospital. Information sought included the biodata, awareness of the STG, publication and use of the STG, the perceived advantages and disadvantages, and suggestions on how to improve its use. Results: There were 155 respondents with a mean age of 34.1 ± 6.4 years and response rate of 77.5%. The level of awareness was 46.5%, with 21.9% having received lessons on the subject; 53.0% received lessons as students. Awareness of the date of the initial introduction of the STG at the national level was 4.5% with 1.3% aware of the current edition of the NSTG. The description of the STG was satisfactory in 27.7% participants. Again only 20.6% currently use the NSTG, with 12.3% rating the entire STG utilization as successful. Conclusion: There is low awareness and poor utilization of the STG among doctors in the facility which may be a reflection of the situation in other health facilities in the country. There is need to encourage the use of this clinical tool to ensure appropriate use of medicines and delivery of health care in resource-limited settings.

   Abstract in French 

Résumé
Contexte: Les directives nationales nigérianes de traitement standard (NSTG) ont été introduites en 2008 et la deuxième édition a été lancée en 2017. Cette étude a évalué le niveau de sensibilisation, d'acceptation et d'utilisation de cet outil dans le système de santé nigérian. Méthodologie: Cette étude a été réalisée à l'hôpital universitaire du Bénin, Benin City, Nigeria. Un questionnaire semi-structuré a été administré aux médecins de l'hôpital. Les informations recherchées comprenaient les données biographiques, la connaissance du STG, la publication et l'utilisation du STG, les avantages et inconvénients perçus et des suggestions sur la manière d'améliorer son utilisation. Résultats: 155 personnes a été interrogés ayant un âge moyen de 34,1 ± 6,4 ans et un taux de réponse de 77,5%. Le niveau de sensibilisation était de 46,5%, 21,9% ayant suivi des cours sur le sujet; 53,0% ont reçu des cours en tant qu'étudiants. La connaissance de la date de la première introduction du STG au niveau national était de 4,5%, avec 1,3% conscient de l'édition actuelle du STG. La description du STG était satisfaisante chez 27,7% des participants. Encore une fois, seuls 20,6% utilisent actuellement le NSTG ; 2,3% estimant que l'utilisation de STG, en entier, était un succès. Conclusion: Les médecins de l'établissement sont peu sensibilisés et il y a l'utilisation faible de STG chez eux : ce qui peut refléter la situation dans d'autres établissements de santé du pays. Il est nécessaire d'encourager l'utilisation de cet outil clinique pour assurer l'utilisation appropriée des médicaments et la prestation des soins de santé dans les pays à ressources limitées.

Keywords: Doctors, hospitals, Nigeria, standard treatment guidelines


How to cite this article:
Ayinbuomwan A S, Isah AO. Standard treatment guidelines: Perception and utilization in a tertiary health care facility in South-South, Nigeria. Ann Afr Med 2019;18:47-50

How to cite this URL:
Ayinbuomwan A S, Isah AO. Standard treatment guidelines: Perception and utilization in a tertiary health care facility in South-South, Nigeria. Ann Afr Med [serial online] 2019 [cited 2019 Apr 20];18:47-50. Available from: http://www.annalsafrmed.org/text.asp?2019/18/1/47/251583




   Introduction Top


The introduction of the Standard Treatment Guidelines (STGs) for use by clinicians in hospitals is intended to promote rational, safe, and cost-effective use of medicines in the health-care system. They are defined as “systematically developed statements designed to assist practitioners and patients in making decisions about appropriate healthcare for specific clinical circumstances.”[1] STG is a compilation of treatment protocols based on clinical diagnostic criteria, therapeutic practice guidelines, and guidelines on the management of diseases. It improves the quality of care and the appropriateness of care and is also used as an educational tool.[2] It provides for therapeutic effectiveness and economically efficient use of medicines by health-care providers, drug manufacturers, marketing agencies, and above all policymakers of the country.

STGs are employed at different points in the therapeutic process ranging from diagnosis, decision on treatment, pharmaceutical supply, and assistance with adherence to prescribed treatment.[2] The development of this document involves experts and clinical specialists who utilize evidence-based information to establish appropriate treatment options for diseases that have been selected based on available morbidity statistics.[3] This document cannot achieve health gains except it is scientifically valid, rigorously developed, and consistent with available scientific evidence. STGs are updated regularly every 2 years to reflect changes in accepted treatment strategies. They are available institutionally, nationally, and internationally. The unavailability or nonadherence to this important therapeutic tool increases variability in treatment, suboptimal patient outcomes, and poor resource utilization.[4] In addition, practitioners become increasingly exposed to medicolegal risks following preventable adverse events to the patient as a result of poor adherence to guidelines. Guidelines have generally been accepted by practitioners as good sources of advice and educational tools tailored toward improving patient quality of care.[5] However, the implementation of STGs is still a challenge in many countries.

The Nigerian National Standard Treatment Guidelines (NSTGs) were introduced in 2008[6] and the second edition has just recently been launched in July 2017. The process of development of this document entailed the participation of expert clinicians in all the subspecialties ensuring consensus and upholding the state of the art and standard of care with endorsement from the Federal Ministry of Health (FMOH). The extent of awareness and utilization of this important document within the hospital setting by medical practitioners in Nigeria is still unknown. There is need to establish the degree of penetration of the concept of the guidelines since guidelines cannot improve patient care unless the end-users are aware of its existence and are actively influenced to use it in their clinical practice. This study, therefore, evaluates the level of awareness, acceptance, and use of this tool among prescribers in a tertiary health-care facility in South-South, Nigerian.


   Methodology Top


This cross-sectional, descriptive study was carried out at the University of Benin Teaching Hospital, in Benin City, Edo State, South-South, Nigeria. This is a Federal Government tertiary hospital with a 850-bed space capacity. A self-administered semistructured questionnaire was designed to assess medical doctor's awareness, knowledge, and attitude toward the implementation of the NSTG within the hospital. This questionnaire contained four sections assessing the following: the sociodemographics of the participants, their awareness of the NSTG, publication and understanding of the NSTG, the perceived advantages and suggestions on how to improve the guideline, and finally, their attitude regarding its implementation in their daily practice. It was distributed to all medical doctors who consented to the study in all departments within the hospital over a 7-month period from January to July 2017.

The data were analyzed using the SPSS software (Statistical Package for the Social Sciences) version 20 (IBM Chicago). Analysis was done systematically and results are presented descriptively as the frequency (percentage) and mean ± standard deviation.


   Results Top


A total of 155 out of 200 medical doctors who received the questionnaires participated in this study; response rate was 77.5%. The mean age of the respondents was 34.1 ± 6.4 years with a range of 21–50. There were more males in this study (67.1%), with three respondents omitting their sex. The mean year of graduation was 7.5 ± 5.0. The level of awareness of the NSTG among the respondents is demonstrated in [Table 1]. Awareness of the existence of the NSTG document was 46.5% (72/155), with only 34.2% (53/155) having seen the document and 21.9% (34/155) having received lessons on the subject. Of these 34 medical doctors who had received previous lessons regarding the NSTG, 52.9% received lessons as medical students, 38.2% after graduation from medical school, while 8.8% did not indicate the period.
Table 1: Assessment of perception and utilization of the national standard treatment guideline among medical doctors in tertiary hospital in South- South Nigeria

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Only 34.2% (53/155) had seen the STG document at any time. Knowledge of the date of the initial introduction of the STG at the national level was 4.5% (7/155), with 1.3% (2/155) having accurate knowledge of the current edition of the NSTG. The description of the STG was satisfactory in only 27.7% (43/155) participants as seen in [Table 1].

[Table 1] also shows the attitude of the medical doctors in their utilization of the NSTG. Only 20.6% (32/155) currently make use of the NSTG, with 12.3% (19/155) rating the entire STG program as successful.


   Discussion Top


Clinical guidelines are evidence-based therapeutic tools which when developed in a transparent and methodical manner help to promote high-quality care by facilitating practice change among medical practitioners. Furthermore, they contain evidence of highest quality and most up-to-date data about prevention, diagnosis, prognosis, therapy vis a vis dosage of medications, risks, benefits, and cost-effectiveness.[7] However, simply developing these may not be sufficient in influencing change if the end-users are not aware of their existence and are also not actively making use of them in their daily practice. This descriptive study evaluated the knowledge, attitude, and practice of the NSTG among medical doctors in a tertiary hospital.

There was a blend of both the young and old (both in age and clinical experience) in this study; however, those less 40 years were predominant (73.0%), being more willing to participate in the study. The average clinical experience among the practitioners was 7.4 ± 5.0 years. The demographic characteristics of medical practitioners such as age and number of years after graduation have been shown to influence their awareness and utilization of guidelines. Other demographic factors that have been identified include institution where medical degree was obtained, participation in postgraduate education, and their additional qualifications.[8],[9] Tunis et al.[10] in 1997, assessing the attitude of internists of the American College of Physicians toward guidelines, found that those who recently graduated had favorable attitudes when compared with their older colleagues. This was corroborated by Bochud et al. in a cross-sectional survey of 174 physicians while assessing knowledge and attitude toward guidelines.[11] However, the New England Healthcare Institute in 2007 found that there was no significant difference in guideline utilization though it was more favorable with younger physicians.[12] The findings of this study highlight the poor publicity during the launch of the document and its poor distribution to doctors in the health-care system. Poor dissemination is a major contributor, as only 34.20% of the practitioners have seen the NSTG throughout their clinical practice. This was corroborated by an earlier study by Hassan et al.[13] in North-Central Nigeria, where <40% of the medical practitioners were aware of the NSTG. Guideline development is usually capital intensive; hence, adequate funding should be directed at placing this document in the hands of end-users. Lack of guideline awareness and familiarization will invariably affect the practitioner's knowledge and adherence. There is need to improve access to the NSTG to reduce wastage and inefficiency in our healthcare system. In addition, guideline dissemination and utilization are time bound to keep pace with the changing standard of care. A number of practitioners have learnt to rely on their judgments and personal experiences in the absence of this document. Clinical guidelines are not a substitute to clinical judgments, and the need for individualization of care requires the clinical discretion of the practitioner in its application. In the absence of these documents, practitioners rely on textbooks and formularies, especially the British National Formulary as noted by two previous studies in this facility.[14],[15] The limitations of drug formularies are first, that they deal with drug management, and not disease management. Second, they are deficient in holistic patient evaluation nor do they outline alternatives to pharmacotherapy. Thus, these alternatives may be a poor reflection of our health facilities since practitioners' adherence to guidelines is a measure of assessing quality of health care.[16] For ease and timely accessibility by the end-users, both hard and soft copies have to be made available by the stakeholders. This is necessary because the greater the efforts required to access guidelines, the less likely their utilization by the end-users. The (FMOH) coordinates the development of the NSTG, in collaboration with the WHO, international organizations, and donor agencies; however, the dissemination and utilization of the document should also be driven by various professional associations and training institutions saddled with the undergraduate and postgraduate medical training. Dissemination of clinical guidelines alone has been shown to be effective in influencing clinical practice.[15]

In this study, only 21.9% of the respondents claimed to have been taught the NSTG either as students or as practicing clinicians. Didactic educational meetings have a vital role in increasing awareness and knowledge of guidelines; however, they are limited if utilized as sole method of dissemination. Multifaceted interventions that have proved effective in influencing guideline utilization in daily practice include educational outreach visits, decision-support systems and other reminders, interactive educational meetings, and mass media approach.[17] Only 32.0% of the medical practitioners in this study make use of the NSTG, and most (87%) adjudged the program as unsuccessful. This may be saying the obvious since STGs have been identified as the first step in ensuring high quality, effective, and economical health-care system in any country.[18]


   Conclusion Top


These findings suggest a low awareness and poor utilization of the NSTG among doctors in the facility which may be a reflection of the national situation. There is need to encourage the use of this clinical tool to ensure appropriate use of medicines and delivery of health care in resource-limited settings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Eccles MP, Grimshaw JM, Shekelle P, Schünemann HJ, Woolf S. Developing clinical practice guidelines: Target audiences, identifying topics for guidelines, guideline group composition and functioning and conflicts of interest. Implement Sci 2012;7:60.  Back to cited text no. 1
    
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WHO. Drug and Therapeutic Committee Training Course. Participants' Guide: Standard Treatment Guideline 2007. Geneva, Switzerland: WHO; 2007.  Back to cited text no. 3
    
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Mulley AG. Inconvenient truths about supplier induced demand and unwarranted variation in medical practice. BMJ 2009;339:b4073.  Back to cited text no. 4
    
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Farquhar CM, Kofa EW, Slutsky JR. Clinicians' attitudes to clinical practice guidelines: A systematic review. Med J Aust 2002;177:502-6.  Back to cited text no. 5
    
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Federal Ministry of Health (FMOH). Standard Treatment Guideline. 2nd ed. Abuja, Nigeria: Federal Ministry of Health; 2016.  Back to cited text no. 6
    
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AGREE Collaboration. Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: The AGREE project. Qual Saf Health Care 2003;12:18-23.  Back to cited text no. 7
    
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Ernst S. Hypertension guideline adherence by private practitioners and primary health care physicians in Pretoria. S A Fam Pract 2005;47:51-4.  Back to cited text no. 8
    
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Anderson RM, Donnelly MB, Dedrick RF, Gressard CP. The attitudes of nurses, dietitians, and physicians toward diabetes. Diabetes Educ 1991;17:261-8.  Back to cited text no. 9
    
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Tunis SR, Hayward RS, Wilson MC, Rubin HR, Bass EB, Johnston M, et al. Internists' attitudes about clinical practice guidelines. Ann Intern Med 1994;120:956-63.  Back to cited text no. 10
    
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Bochud M, Cornuz J, Vader JP, Kamm W, Burnand B. Are internists in an non-prescriptive setting favourable to guidelines? A survey in a department of internal medicine in Switzerland. Swiss Med Wkly 2002;132:201-6.  Back to cited text no. 11
    
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Kenefick H, Lee I, Fleishman V. Improving physician adherence to clinical practice guideline: Barriers and strategies for change. New England Healthcare Institute, Cambridge, MA. 2008. p. 7.  Back to cited text no. 12
    
13.
Hassan A, Abduhalli GA, Ahmed AA, Sabiu A, John U, Ezekeil G. et al. Assessing prescribers awareness of essential medicines list, hospital drug formulary and utilization of standard treatment guidelines in a tertiary healthcare facility in North Central Nigeria. Alex J Med 2017;03:6-9.  Back to cited text no. 13
    
14.
Isah AO, Isah EC. Drug information sources utilized by junior hospital doctors in Nigeria. Natl Postgrad Med J 1998;5:23-7.  Back to cited text no. 14
    
15.
Olowofela A, Ayinbuomwan SA, Isah AO. Sources of information on the use of medicines utilised by resident doctors in a tertiary health care facility in Nigeria. Highland Med Res J 2017;17:81-5.  Back to cited text no. 15
    
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Siddiqi K, Newell J, Robinson M. Getting evidence into practice: What works in developing countries? Int J Qual Health Care 2005;17:447-54.  Back to cited text no. 16
    
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Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thomson MA, et al. Closing the gap between research and practice: An overview of systematic reviews of interventions to promote the implementation of research findings. The Cochrane effective practice and organization of care review group. BMJ 1998;317:465-8.  Back to cited text no. 17
    
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Hettihewa LM, Wimalasena I, Dadallage T. Knowledge of Sri Lankan government medical practitioners and medical students on standard treatment guidelines; Regional cross sectional survey. Int J Nutr Pharmacol Neuro Dis 2013;15:108-13.  Back to cited text no. 18
    



 
 
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