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Study examines physician behavior
For a variety of reasons, a surprising number of doctors are not following guidelines that could help them treat patients better. But there are some steps that can be taken to overcome this, according to a recent study from researchers at the University of Michigan in Ann Arbor and the Johns Hopkins School of Public Health in Baltimore.
Published in the Oct. 20, 1999, issue of the Journal of the American Medical Association, "Why don’t physicians follow clinical practice guidelines? A framework for improvement" concludes that physicians often fail to follow guidelines because they don’t have the information, time, or readiness to change. And, in the case of guidelines for preventive health advice, lack of confidence is the most likely reason physicians give for not following recommendations.
The study was conducted by Michael Cabana, MD, MPH, a pediatrician and lecturer in pediatrics at the University of Michigan Health System, and his former colleagues at the Johns Hopkins School of Public Health. The study reviewed the results of 120 physician surveys contained in 76 scientific papers published over the last 30 years. In each, doctors reported on what they perceived to be the biggest barriers, in terms of knowledge, attitudes, and behavior, which kept them from following the medical guidelines for specific diseases.
"Despite the fact that physicians have evidence-based guidelines at their disposal for dozens of conditions, they’re having similar problems across the board in implementing them in their own practice," says Cabana. "If these guidelines are going to have an impact on the way patients are treated, we need to understand the barriers that exist and find ways to overcome them."
A glut of guidelines
Increasingly, over the past 10 years, groups that include medical societies, government agencies, and nonprofit groups have brought in experts to examine the current state of knowledge about different diseases and develop guidelines to prevent or treat them, according to the study. At one point, the American Medical Association had catalogued over 1,500 different practice guidelines.
The resulting consensus statements aim to help both physicians and patients make the best decisions about health care. And as medical science advances, these organizations revisit, revise, and reissue their guidelines so that physicians can keep current without having to read numerous research journals.
But, says Cabana, the mere existence of a guideline doesn’t necessarily mean that all physicians will know of it, know enough about it, agree with it, be confident enough, or even allowed by hospitals and insurers to follow it.
"We found, based on our review of the studies, that there are a number of common barriers to guideline use," he says. "For example, in 78% of studies that surveyed doctors about awareness of a particular guideline, more than 10% of the respondents said they simply weren’t aware of it. And an even larger number were not familiar enough with the guideline to follow its recommendations."
Also, individual doctors may not agree entirely with the guidelines issued by their own peers, leading them to choose a different course of treatment, adds Cabana. Some physicians see certain guidelines as being oversimplified or "cookbook," not practical, a threat to their autonomy, or not completely justified by scientific evidence.
In all, lack of agreement with a guideline led more than 10% of doctors in a majority of surveys to reject the guidelines’ advice. But, Cabana says, doctors are less likely to disagree when asked about a particular guideline than they are when asked about guidelines in general.
More important than lack of agreement, the researchers found, is a physician’s belief that he cannot perform the actions set out by a guideline, or the expectation that he won’t get the desired outcome even if he does. According to Cabana, the authors discovered that 68% and 75%, respectively, of the surveys that reported those barriers related to guidelines that involved preventive health education and counseling.
"It’s advice giving, not prescriptions or procedures, that seems to trip up the most doctors," Cabana explains. "Even telling people to stop smoking appears to seem pointless to many physicians because they may not feel they can make a difference."
An interesting area that needs more research, he adds, is the barrier of inertia — i.e., where physicians do not adopt new guidelines because they have no motivation to change. Though few of the surveys analyzed by Cabana and his colleagues looked at this factor, all of those that did reported it was a problem for more than 20% of doctors surveyed. Correspondingly, the authors say, guidelines that tell doctors to stop an old, outdated practice might be harder for them to obey than guidelines that suggest adding a new one.
What’s out of the physician’s control?
Finally, the report looked at external barriers, factors outside physicians’ control that might keep them from following a guideline. Patients themselves present a major hurdle; the fact that patient preferences may not match national recommendations was cited by more than 10% of doctors in all the surveys that looked at this factor.
Also seen as problems by a large percentage of physicians were the lack of a reminder system, lack of counseling materials, insufficient staff, poor reimbursement or increased costs for a procedure, and increased liability. A simple lack of time figured strongly in many cases.
Cabana says that this study should not, in and of itself, be the basis for new guidelines. But at the same time, it does present evidence with a number of implications for guideline developers, educators, and practice managers.
Guideline developers need to do away with the Field of Dreams attitude that when it comes to guidelines, "publish them and they [physicians] will come," says Cabana. "The research shows that this is definitely not the case," he notes, "and that guidelines developers need to be sensitive to the variety of barriers physicians face in following guidelines, and act accordingly." If you are going to put together these guidelines, you have to be sensitive to these barriers.
Those who educate physicians, meanwhile, should make note of the findings regarding the difficulties physicians experience in counseling patients on preventive health measures. "One of the barriers most often cited was lack of confidence in the ability to follow a guideline and whether it makes a difference," says Cabana. This came up most often in the case of counseling on things like smoking cessation and weight loss, he notes, "and maybe this is an indication that physicians need more training in communication."
Wisely using resources, staff time
At the same time, practice managers need to recognize that the decisions they make in terms of resource allocation can add to or help in overcoming barriers. "For example, when it comes to counseling, practice managers may need to consider that the physician may not be the most cost-effective person to deliver smoking cessation advice in accordance with guidelines. Perhaps that is better done by nurses," says Cabana.
The important thing for guideline developers, educators, and practice managers to keep in mind, says Cabana, is that the failure of physicians to follow guidelines is not necessarily the result of conscious decisions on their part. "What we are saying is that there are a number of barriers to following guidelines," he notes, "and that there are actions all three groups can undertake to assist physicians in overcoming these barriers."
(For more information, contact Michael Cabana, MD, MPH, University of Michigan Health System, D3255 MPB0718, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0719. E-mail: cabana@umich. edu.)