Abstract
BackgroundReviews of guideline implementation recommend matching strategies to the specific setting, but provide little specific guidance about how to do so. We hypothesized that the highest level of guideline-concordant care would be achieved where implementation strategies fit well with physicians' cognitive styles.MethodsWe conducted an observational study of the implementation of guidelines for hypertension management among patients with diabetes at 43 Veterans' Health Administration medical center primary care clinics. Clinic leaders provided information about all implementation strategies employed at their sites. Guidelines implementation strategies were classified as education, motivation/incentive, or barrier reduction using a pre-specified system. Physician's cognitive styles were measured on three scales: evidence vs. experience as the basis of knowledge, sensitivity to pragmatic concerns, and conformity to local practices. Doctors' decisions were designated guideline-concordant if the patient's blood pressure was within goal range, or if the blood pressure was out of range and a dose change or medication change was initiated, or if the patient was already using medications from three classes.ResultsThe final sample included 163 physicians and 1,174 patients. All of the participating sites used one or more educational approaches to implement the guidelines. Over 90% of the sites also provided group or individual feedback on physician performance on the guidelines, and over 75% implemented some type of reminder system. A minority of sites used monetary incentives, penalties, or barrier reduction. The only type of intervention that was associated with increased guideline-concordant care in a logistic model was barrier reduction (p < 0.02). The interaction between physicians' conformity scale scores and the effect of barrier reduction was significant (p < 0.05); physicians ranking lower on the conformity scale responded more to barrier reduction.ConclusionGuidelines implementation strategies that were designed to reduce physician time pressure and task complexity were the only ones that improved performance. Education may have been necessary but was clearly not sufficient, and more was not better. Incentives had no discernible effect. Measurable physician characteristics strongly affected response to implementation strategies.
Highlights
Reviews of guideline implementation recommend matching strategies to the specific setting, but provide little specific guidance about how to do so
The participating VA Medical Centers (VAMCs) are located in 27 states, and in 19 of the 21 Veterans Integrated Service Networks (VISNs)
Even though all patients in the VAMCs are supposed to have a primary care provider, it was still challenging to meet the criterion that more than 50% of a patient's outpatient medical clinic visits had to be to one of our participating primary care physicians (PCPs)
Summary
Reviews of guideline implementation recommend matching strategies to the specific setting, but provide little specific guidance about how to do so. We developed a typology of cognitive styles, postulating that there are four archetypes of physician response patterns to new information intended to change practice [11]. These four are the "seeker", strongly evidence-based and willing to act on evidence almost regardless of other factors; the "receptive", who regards data as the basis of knowledge but attends to setting and social issues; the "traditionalist", who regards clinical experience and authority rather than data as the basis of knowledge; and the "pragmatist", who is less concerned about the basis of knowledge than about the practicalities of getting patients seen. We have published a measurement instrument for these scales [12], which we hereafter term the "EPC instrument."
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