Targeted clinical audits immediately following the establishment of clinical practice guidelines for multiple sclerosis in 17 neurology departments: A pragmatic and collaborative study.
Following the publication practice guidelines for multiple sclerosis by a group of neurologists (multiple sclerosis study group [GRESEP]), the primary objective of this study was to compare the reality of practice to the guidelines according to the targeted clinical audit (TCA) method. The study was conducted at 17 neurology sites and was administered during two periods of MS care (diagnostic - TCA-DIAG, and disease course - TCA-EVOL). Two complementary surveys were done on the record keeping and the root causes of the deviations. The percentages of compliance ranged from 8 to 98% for the TCA-DIAG, and from 15 to 99% for the TCA-EVOL, with wide disparity between sites. The audits were able to identify causes of the flaws in traceability or accessibility. At the end of the study, despite its limitations, we think that the sharing of the results from different sites provided interesting approaches for the use of the assessment criteria defined by GRESEP in a complete audit cycle. This study is to our knowledge the first report of an experiment in which guidelines were created, and subsequently followed by the development of assessment criteria and then the performance of targeted clinical audits using them, all by the same participants.


BACKGROUND
Clinical practice guidelines (CPGs) are intended to help practitioners and patients make informed treatment choices, but their integration into actual practice remains problematic. This study was done immediately following the publication of CPGs for multiple sclerosis (MS) by the multiple sclerosis study group [GRESEP]. The primary objective was to generate quality criteria, to test them within the same group, and to analyze the observed deviations.


METHODS
The study was conducted in the 17 voluntary departments that had participated in the development of the CPGs. The targeted clinical audit method was administered during two periods of MS care (diagnostic - TCA-DIAG, and disease course - TCA-EVOL). All the files were evaluated by a clinical research technician using digital format, which ensured thoroughness of the collection. Two complementary surveys were done on the record keeping and the potential causes of the deviations.


RESULTS
The percentages of compliance to the criteria ranged from 8 to 98% (out of 240 files) for the TCA-DIAG, and from 15 to 99% (221 files) for the TCA-EVOL, with wide disparity between sites (interquartile distance ranges: TCA-DIAG between 0% and 55%; TCA-EVOL between 0% and 70%). The mean percentage of compliance with all the criteria as measured by the TCA-DIAG was 83.9% for the sites with digital files vs. 76.4% for those with only paper files (P<0.01). For the TCA-EVOL, the difference was not significant. Explanations for the observed deviations were suggested (1 to 9 according to the participants).


CONCLUSIONS
The quantified results could not be compared to other studies given the unique nature of the experiment. The importance of the traceability of practices in the patient files was discussed and assessed with regard to continuity and safety of care, as well as the medical-legal perspectives. Causes of lack of compliance were suggested (particularly the absence of reminders, the lack of means and/or time). Despite the limitations of the study, we think it is advisable that when a group becomes involved in the development of CPGs that they follow with the development of assessment criteria in order to evaluate the validity as well as their character as intermediate indicators of the quality of practices.
40, rue Franklin, 94190 Villeneuve-Saint-Georges, France. Electronic address: gerard.lairy@orange.fr.
G
G
Lairy
Pôle de Neurologie, Hôpital Roger-Salengro, CHRU de Lille, 2, avenue Oscar-Lambret, 59000 Lille, France.
H
H
Zephir
Pôle des Neurosciences Cliniques, Service de Neurologie, CHU de Bordeaux Pellegrin Tripode, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France.
J-C
JC
Ouallet
Service de Neurologie, CHU de Rennes, 2, rue Henri-Le-Guilloux, 35000 Rennes, France.
E
E
Le Page
Service de Neurologie, CHU de Nantes, 44093 Nantes cedex, France; Inserm UMR643, Pavillon Jean-Monnet - Hôtel-Dieu, 30, boulevard Jean-Monnet, 44093 Nantes 01, France.
D
D
Laplaud
Service de Neurologie, Fondation Rothschild, 25, rue Manin, 75019 Paris, France.
C
C
Bensa
Service de neurologie, CHU de Strasbourg, Inserm UMR 1119, CIC de Strasbourg Inserm 1434, Fédération de Médecine translationnelle de Strasbourg (FMTS), 11, rue Humann, 67000 Strasbourg, France.
J
J
De Seze
D000328:Adult; D054869:Clinical Audit; D018450:Disease Progression; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D019538:Health Care Surveys; D006801:Humans; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D009103:Multiple Sclerosis / Q000175:diagnosis / Q000628:therapy*; D009462:Neurology / Q000592:standards*; D017410:Practice Guidelines as Topic
Audit clinique ciblé; Clinical audit; Clinical practice guideline; Health care; Multiple sclerosis; Outcome and process assessment; Recommandations de bonnes pratiques cliniques; Sclérose en plaques; Targeted clinical audit; Évaluation des résultats et des processus (soins de santé)