背景:临床实践指南(CPGs)是政策和临床实践中的常用工具,可在床边告知临床决策,卫生设施的治理,健康保险公司和政府支出,病人的选择。南非的卫生部门正在向国家医疗保险体系过渡,旨在以其他初级卫生保健举措为基础,改变以前的隔离状态,不公平的服务。在这些计划中,CPG是提供标准化和具有成本效益的护理的不可或缺的工具。目前,没有公认的标准方法来发展,在南非有效或有效地适应或实施CPG。我们从国家一级利益相关者的角度探讨了当前的参与者;驱动因素;以及初级保健CPG发展的背景和过程。
方法:我们使用了定性方法。采样最初是有目的的,随后是滚雪球和进一步抽样,以达到初级保健服务提供者的代表性。对个人的深入访谈进行了记录和逐字转录。我们使用主题内容分析来分析数据。
结果:我们从2014年6月至2015年7月进行了37次深度访谈。我们发现,由于缺乏用于技术和方法工作的人力和资金资源,CPG的开发和实施受到阻碍;以及国家和省级卫生部门之间的关系;缺乏商定的CPG开发和实施系统。一些CPG贡献者坚定不移地努力改进旨在加强沟通的流程,使用证据,和透明度,以确保产生可信的指导。许多受访者有共同的价值观,被驱使去解决不平等问题,然而,资源缺口被认为为商业利益或个人议程创造了有利的环境,以推动CPG的发展进程。
结论:我们的发现发现了CPG开发过程中的优势和差距,需要国家标准来指导CPG的制定和实施。根据我们的发现和参与者的建议,一个可能的前进道路是,南非有一个中央协调的CPG单位,通过设计支持合作的进程来解决这些需求和分散的方面,跨部门和跨学科的透明度和可信度。这一举措将需要充足的资源来建设能力,并确保支持为南非初级保健提供高质量的CPG。
BACKGROUND: Clinical practice
guidelines (CPGs) are common tools in policy and clinical practice informing clinical decisions at the bedside, governance of health facilities, health insurer and government spending, and patient choices. South Africa\'s health sector is transitioning to a national health insurance system, aiming to build on other primary health care initiatives to transform the previously segregated, inequitable services. Within these plans CPGs are an integral tool for delivering standardised and cost effective care. Currently, there is no accepted standard approach to developing, adapting or implementing CPGs efficiently or effectively in South Africa. We explored the current players; drivers; and the context and processes of primary care CPG development from the perspective of stakeholders operating at national level.
METHODS: We used a qualitative approach. Sampling was initially purposeful, followed by snowballing and further sampling to reach representivity of primary care service providers. Individual in-depth interviews were recorded and transcribed verbatim. We used thematic content analysis to analyse the data.
RESULTS: We conducted 37 in-depth interviews from June 2014-July 2015. We found CPG development and implementation were hampered by lack of human and funding resources for technical and methodological work; fragmentation between groups, and between national and provincial health sectors; and lack of agreed systems for CPG development and implementation. Some CPG contributors steadfastly work to improve processes aiming to enhance communication, use of evidence, and transparency to ensure credible guidance is produced. Many interviewed had shared values, and were driven to address inequity, however, resource gaps were perceived to create an enabling environment for commercial interests or personal agendas to drive the CPG development process.
CONCLUSIONS: Our findings identified strengths and gaps in CPG development processes, and a need for national standards to guide CPG development and implementation. Based on our findings and suggestions from participants, a possible way forward would be for South Africa to have a centrally coordinated CPG unit to address these needs and aspects of fragmentation by devising processes that support collaboration, transparency and credibility across sectors and disciplines. Such an initiative will require adequate resourcing to build capacity and ensure support for the delivery of high quality CPGs for South African primary care.