Abstract
Clinical guidelines have probably existed for thousands of years. The management of urethritis is mentioned in the Bible, 1 and centuries before this, the Egyptian physician Imhotep (2667–2648 BC), acknowledged by William Osler as the father of medicine, 2 is credited with writing a number of ‘instructions’ that describe the detailed management of certain clinical conditions. 3,4 Guidelines for the specific management of sexually transmitted infections (STIs) have been produced for a number of years, initially in the USA in the 1980s by the Centers for Disease Control and Prevention (CDC), a government health agency developed at the end of World War II, evolving from a malaria control programme. 5,6
In the UK, the production of national evidence-based STI management guidelines began in the mid-1990s with the publication of a guideline on gonorrhoea, 7 followed by one for chlamydia. 8 The process of regular formal guideline production began in October 1997 when the two national specialist societies at the time, the Association for Genitourinary Medicine (AGUM) and the Medical Society for the Study of Venereal Diseases (MSSVD) established a Clinical Effectiveness Group (CEG). The CEG was given the responsibility of producing and updating all evidence-based national guidelines and standards for UK specialists in genitourinary medicine. Twenty-four CEG guidelines were subsequently developed by individual authors and published collectively in 1999 as a supplement to the journal Sexually Transmitted Infections. 9 They have been updated regularly since then. AGUM and MSSVD merged in 2003 to form the British Association for Sexual Health and HIV (BASHH) and its CEG currently comprises seven members who oversee the production of all guidelines. There are now 32 guidelines, plus associated documents, all of which are freely available on the BASHH website. 10
The CEG was interested in assessing how many visits are made to the ‘Guidelines’ section on the BASHH website and, in particular, the popularity of specific guidelines. Internet hits are logged regularly on an administration website and the precise destination of web traffic can be monitored.
METHOD
The administration section of the BASHH website was accessed and data analysed on a month-by-month basis from 1 January to 31 December 2009. This gave general information on which parts of the website were being viewed and a ‘top 3’ list was compiled (Table 1).
Top three monthly destinations on the BASHH website (number of hits in brackets)
Further details of which particular guidelines were being accessed were obtained by methodically looking at every document viewed each month. A list of guidelines, in ranking order of popularity, was then complied for each month and these data were then averaged out over the whole year to identify the ‘Top 5’ guidelines for the year (Table 2).
Top five guidelines for 2009 (based on average number of hits per guideline)
RESULTS
The guidelines webpage was consistently the most popular specific destination on the main BASHH website, once the homepage had been entered, ranking top choice of all visitors for every month of 2009 (see Table 1 and Figure 1). Occasionally, it was accessed directly bypassing the homepage.
Graph of monthly hits on ‘Guidelines’ webpage
DISCUSSION
The ‘guidelines’ section of the BASHH website is consistently the most popular specific destination for online visitors. Interest seems to drop slightly in the summer months and in December, presumably due to holidays from work.
Detailed month-by-month analysis of every document viewed showed remarkable consistency in the popularity of certain guidelines throughout the year, with Herpes 2007 and Screening and Testing 2006 jostling for first and second places throughout the year, and Syphilis competing with Gonorrhoea for third and fourth places regularly! Overall, herpes proved to be the most viewed guideline of 2009.
Does the popularity of a certain guideline indicate the conditions that clinicians are most uncertain about managing? It is difficult to draw this conclusion because being an open-access website, the popularity may have arisen as a result of hits from non-clinicians. For example, the herpes guideline is mentioned on the website of the Herpes Virus Association, 11 a UK-based patient information charity, which carries a direct link to it on the BASHH CEG guidelines page.
Guidelines may also prove popular simply out of interest rather than clinical uncertainty (newly released draft guidelines attracted short flurries of interest) and audits may also affect the number of hits a document receives from clinicians. During 2009, a national audit was undertaken looking at asymptomatic screening in UK GUM clinics, 12 which may explain some of the popularity of the screening and testing document.
Perhaps issues of access to the guidelines might also be pertinent? The BASHH website is the main way in which the CEG guidelines can be accessed conveniently, although most guidelines are subsequently published in peer-reviewed UK journals as well. In the USA, the CDC not only has a website for its STI guidelines (with over 200,000 hits a year it is one of the CDC's most visited sites), but it also prints hard copies of documents for dissemination as well as producing online slide sets and downloads for palm-top computers. 6
It will be difficult to fully understand why certain guidelines are visited more than others. Nevertheless, it is clear that the CEG guidelines are an important and very popular part of BASHH's work.
Several joint guidelines have been produced with other sexual health stakeholders and many CEG members represent the Group on other committees. The CEG continues to produce new and updated guidelines – the production of BASHH patient information leaflets linked to CEG guidelines is the next major project. It is hoped that such work continues to benefit clinicians and patients alike – doubtless Imhotep would have approved!
Footnotes
ACKNOWLEDGEMENTS
The author thanks the other members of the Clinical Effectiveness Group for their valuable comments on this submission: Dr Keith Radcliffe (Chair), Dr David Daniels, Dr Mark FitzGerald, Dr Margaret Kingston, Dr Gill McCarthy and Dr Ann Sullivan. Thanks also to the BASHH webmaster, Dr Ade Apoola, for technical advice.