ANN ARBOR, Mich. - A surprising percentage of doctors are not following national guidelines that could help them treat patients better because they don't have enough information, time, or readiness to change - or enough confidence in their ability to do everything the guidelines recommend, according to a new study.
When it comes to guidelines for preventive health advice, lack of confidence is the most likely reason physicians give for not following recommendations. But better educational efforts could help reverse this tendency and ensure that patients get consistent and up-to-date care, say the authors of a report published in the Oct. 20 issue of the Journal of the American Medical Association.
The study reviewed the results of 120 physician surveys, contained in 76 scientific papers published over the last 30 years. In each, doctors reported the biggest barriers of knowledge, attitudes and behavior that keep them from following the medical guidelines for specific diseases. The study was conducted by Michael Cabana, M.D., 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 authors have all been involved separately in the development of different practice guidelines, and pooled their resources to look at the problems facing the implementation of such guidelines in general.
"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."
Increasingly over the past 10 years, a number of medical societies, government agencies and non-profit groups have gathered experts to examine the current state of knowledge about different diseases and develop guidelines to prevent or treat them. 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 common themes running through these studies, common barriers to guideline use," he says. "For example, in 78 percent of studies that surveyed doctors about awareness of a particular guidelines, more than 10 percent of doctors said they simply weren't aware of it. An even larger number were not familiar enough with the guideline to follow its recommendations."
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 too 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 percent of doctors in a majority of surveys to reject the guideline's 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 physicians' belief that they cannot perform the actions set out by a guideline, or their expectation that they won't get the desired outcome even if they do. Interestingly, the authors discovered that 68 percent and 75 percent, respectively, of the surveys that reported these 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. He notes that 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 - physicians not adopting new guidelines because they're stuck in their old way of doing things or 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 percent 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.
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 percent 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 stresses that this study should not itself be the basis for new guidelines, but that there are implications for guidelines developers, who should be sensitive to the barriers that physicians face when following recommendations.
The study, he adds, should also influence the way guideline-adherence surveys are conducted. More surveys should ask doctors about the importance of several or many different barriers, rather than just one. And, guideline authors who want to improve the number of physicians adhering to their recommendations should do a survey before they start, to see what barriers exist.
Furthermore, the fact that lack of confidence among physicians was so common for preventive health guidelines also has implications for the medical educators who train doctors and provide continuing medical education.
And, Cabana adds, the practice administrators in large health care organizations who make nursing staff and reimbursement decisions, and who schedule physician time, also have an impact in helping create or overcome these barriers as well.