Guidelines for GPs are often based on evidence and studies performed outside of general practice itself. This affects doctors’ judgements of the risk-to-benefit ratio of treatments and the performance of diagnostic tests.
As Tania Winzenberg, Professor of chronic disease management at the University of Tasmania, and I write in the Medical Journal of Australia today, interventions (such as medications and other treatments) are often tested in hospitals and other settings where the patient cohort is markedly different to the one seen in primary care.
A study from the United Kingdom indicates GPs ignore advice from guidelines not relevant to general practice. This means GPs could ignore potentially good advice, disadvantaging their patients and increasing costs.
General practitioners
General practice provides the majority of medical primary health care for Australians. About 85% of the Australian population see their GP at least once a year.
More than 137 million GP medical services were delivered by 33,279 general practitioners in 2014-15. In 2011-12, general practice spending was A$14.2 billion, equating to 9.7% of total health expenditure. GPs, the taxpayer and patients would all wish to believe this expenditure provided effective, safe and high-value services.
The reality is somewhat different, for several reasons.
Unlike many specialists, GPs see a wide range of medical conditions. Australian data from the BEACH study show 167 conditions form 85% of a GP’s work compared to five that form the same proportion of a specialist’s.
In half of all GP consultations, it is not possible to make a diagnosis that fits with the diagnostic criteria of the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD 10), the current international classification of disease. This is not because GPs are bad at diagnosis but because much of what they see is mild illness; the symptoms of which are vague and fleeting and that often resolve on their own.
So one the of primary roles of GPs is to rule out significant illness; and if they suspect something sinister, to take appropriate action which may result in hospital or specialist referral.
National guidelines
The Australian health care system requires patients be reviewed and assessed by a GP first before they can access Medicare subsidies for specialist treatment. This ensures those referred for specialist review have a high probability of significant illness. This in turn keeps the cost of specialist care down and ensures the patient sees the most appropriate specialist.
Many patients, particularly as they age, have multiple problems (multimorbidity), which complicates diagnosis and treatment. To ensure GPs provide consistent care among themselves, that patients are referred in an appropriate manner to specialists and hospitals, and that care is as safe as possible, guidelines have been developed to assist GPs.
These work a bit like a GPS in your car. They offer advice on how to get to where you need to be but are not infallible and it is sometimes wise to ignore their advice.
The National Health and Medical Research Council has developed protocols for guideline development that rely on what are called levels of evidence. There are four levels of evidence and these are listed in order of reliability: