Audit of clinical practice guidelines in suicide prevention: who is the auditor?

Abstract

The term “audit” literally means “official examination of accounts” or “searching examination” (Fowler & Fowler, 1964). In suicidology the concept has traditionally involved clinicians pursuing a clinical and psychosocial “psychological autopsy” in which detailed information about the deceased has been collated. As a result there have been studies from a number of countries which have provided valuable information about the potential for suicide prevention (Cheng, 1995; Conwell et al., 1996). In addition to the more focused psychological autopsy studies, there have been several large surveys including those from Finland (Kerkhof, 1999), England (National Confidential Inquiry, 1999), and Australia (Burgess et al., 2000). These have all documented deficits in the assessment and management of people who have suicided. For example, the Finnish work demonstrated that depression was not adequately assessed or treated (Lonnqvist, 2000), and the English and Australian studies concluded that approximately 20% of suicides of those who had had contact with psychiatric services could have been prevented by the optimum assessment and treatment of depression, more attention to staff-patient relationships and better continuity of care. Such findings have formed the basis for the introduction of evidence-based guidelines for suicide prevention services. However, there are formidable barriers to demonstrating their effectiveness, particularly because of the low base rate of suicide and ethical constraints, which make randomly controlled trials impractical. Therefore, rather than a reduction in suicide being assessed by outcome research, process studies of clinical practice have been undertaken, with the expectation that if guidelines are followed, then more effective management will result and suicide should be less likely. However, it has been demonstrated in some clinical areas that guidelines are often not followed (Cabana et al., 1999). Barriers include lack of familiarity or agreement with guidelines, the inability to overcome previous practice habits, the absence of external monitoring of performance, and the belief that such guidelines downplay the individual clinician’s expertise and experience (Cabana et al., 1999; Davis & Taylor-Vaisey, 1997). It is also sobering that a randomized controlled trial examining the effect of clinical practice guidelines and practice-based education on detection and outcome of depression, the condition most often associated with suicidal behavior, failed to provide improvement in the recognition of, or recovery from, depression (Thompson et al., 2000). This was in contrast to the positive results from nonrandom controlled studies such as that of Rutz et al. (1992) in Gotland. Nevertheless, clinical practice guidelines are a fact of life, and their effectiveness has been demonstrated in other clinical areas, for example in acute myocardial infarction, where there are more inpatient deaths if clinical care is not concordant with recommended guidelines (Scott & Harper, 2002). The question arises of who should audit the implementation and functioning of such clinical guidelines. Traditionally self or peer review has been undertaken, and, more recently, bodies such as the Commission for Health Improvement (2002) in the United Kingdom have been established to ensure improvement in patient care. However, the possibility that excess regulation and auditing could be counter-productive has been raised by Walshe (2002) and Goldberg (2002). Indeed, Walshe (2002) referred to the “regulatory state” (Majone, 1994) or “audit society” (Power, 1997) in commenting on the growth of such scrutiny. An alternative to the establishment of new and specialized auditing authorities would be to involve existing government auditing departments. Traditionally this has occurred when there has been political or public interest in a specific issue, and it could be argued that suicide prevention falls into this category. While not having specific knowledge of suicide prevention, such bodies have wide ranging powers of inquiry and their objective assessment would be beyond question.