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

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.

INTRODUCTION

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

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

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

Awareness of the NSTG
Assessment questions	Yes, n (%)	No, n (%)	No response, n (%)
Awareness of the existence of the NSTG ?	72 (46.5)	83 (53.5)	0
Previously taught about the NSTG?	34 (21.9)	121 (78.1)	0
When were you taught about NSTG?	34 (21.9)	102 (65.8)	19 (12.3)
Knowledge of NSTG
Assessment questions	Satisfactory response	Unsatisfactory response	No response
Year of development of the NSTG?	7 (4.5)	6 (3.9)	142 (91.6)
Present edition of NSTG in use?	2 (1.3)	9 (5.8)	144 (92.9)
Definition of NSTG?	43 (27.7)	15 (9.7)	97 (62.6)
Advantages of NSTG?	20 (12.9)	7 ( 4.5)	128 (82.6)
Frequency of revision of NSTG?	9 (5.8)	34 (21.9)	112 (78.7)
Utilization of the NSTG
Assessment questions	Yes	No	No response
Do you presently use the NSTG?	32 (20.6)	122 (78.7)	1 (0.6)
Use of NSTG during internship?	21 (13.5)	132 (85.2)	2 (1.3)
Personal assessment of the success of the NSTG?	19 (12.3)	135 (87.1)	1 (0.6)

NSTG=National standard treatment guideline

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

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.[89] 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.[1415] 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

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.