Article

Audits cliniques ciblés dans les suites immédiates de l'établissement de recommandations de bonnes pratiques cliniques pour la sclérose en plaques, dans 17 services de neurologie.
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. CONTEXT:
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. MATERIALS AND
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). DISCUSSION AND CONCLUSION: 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.
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Langue : ANGLAIS