Clinical guidelines - an historical retrospect
The Unit for Health Services Research at the Norwegian General Scientific Research Council (the Unit is currently part of the Norwegian Institute of Public Health) proposed guidelines for a «blood pressure reduction programme» as early as 1978. Subsequent clinical guidelines for prevention of cardiovascular disease have been further developed over the years in order to quality assure recommended preventive actions. In 1980, more than 70 % of doctors in the county of North-Trøndelag stated that they wanted guidelines for treatment of hypertension, and thereby empirically confirmed that an action programme for this type of treatment was needed. A detailed action programme was sent to the general practitioners (GPs) and to both hospitals in the county. An evaluation three years later showed that the action programme still had massive support (3).
A cross-disciplinary group developed the first national action programme in 1986. The group consisted of health service researchers, health economists, epidemiologists, blood pressure researchers, hospital doctors and the reference group for hypertension in the Norwegian College for General Practice (NCGP). The programme (revised in 1993) suggested higher thresholds for blood pressure treatment than corresponding guidelines in other countries; a discrepancy that caused debate. Hospital- based opinion leaders were especially critical; the Norwegian Society of Cardiology quickly released other guidelines that recommended lower and age-independent thresholds for intervention. Critics of the higher thresholds proposed by NCGP, claimed that the prevalence of stroke was likely to become higher in Norway than in other European countries (1). Nevertheless, it did not occur (4). The programmes from 1986 and 1993 were both printed in stocks of about 20 000 and distributed freely to the two levels of health care in the Norwegian health care services (primary health care and secondary specialist health care services).
This time-period was characterised by a firm belief in that development and distribution of clinical guidelines would automatically ensure the quality of preventive measures in medicine. In 1994, however, a summary of international literature in the field gave the impression that this was not quite as simple (5). It was therefore recommended that various strategies should be used to actively implement guidelines (5).
In 1991, a Norwegian study showed that eight of ten doctors considered guidelines for hypertension and diabetes mellitus to be useful, and that nine of ten doctors wished to receive revised versions. Nevertheless, when the degree to which guidelines affected clinical practice was assessed, one found a large discrepancy between their positive attitude towards guidelines and what they actually did in clinical practice. This concerned both patients with hypertension and patients with diabetes mellitus (6). Even a multifactorial implementation strategy did not improve adherence to guidelines to any significant degree (6). At the time it seemed most appropriate to conclude that lack of implementation partly concerned difficulties with prioritising the large population in question, even though the thresholds for intervention were set higher than in other countries. It also became clear that the recommended «theoretical» approach was not that easy to implement into clinical practice. As several of the doctors said: «Guidelines are fine, but they are not really suitable for my patients» (6).
When the time had come to revise the guidelines from 1993, it was not possible for NCGP's reference group to provide financing, despite contacting all public sources that had contributed to the 1993 programme. A stock of 22 000 booklet, with a short version of the guidelines to put on the desk, was budgeted to cost 600 000 NOK. NCGP's professional work was meant to be unpaid. The reference group, which consisted of GPs with clinical and academic competence, found that the two previous programmes had involved extensive professional compromising, and that public health aspects had not been sufficiently emphasised. All these issues caused the group to publish the guidelines for primary care in the Journal of the Norwegian Medical Association. Four articles were published; two covered general challenges concerning generation and implementation of new knowledge in general practice, one concerned advice on lifestyle and one was on medical preventive measures.