Practice Guideline Adherence Research Articles

Physician Prescribing Patterns of Innovative Antidepressants in the United States: The Case of MDD Patients 1993–2007

Innovative antidepressants such as SSRIs and SNRIs have been widely adopted. However, the differences in their adoption across patients' and physicians' characteristics, geographic regions, and insurance status need to be further explored. This study was trying to disentangle the patterns of physician antidepressant prescribing and medication choice for major depressive disorder treatment. A retrospective cross-sectional study was conducted using the 1993-2007 National Ambulatory Medical Care Survey database. A multinomial logistic regression with the Heckman two-step selection procedure was applied to capture the two-step nature of physician prescription decision making. The weighted logistic regression indicated that patients' race/ethnicity and primary source of payment for services, physician ownership status, and physicians' practice regions were associated with differential likelihood of physician' antidepressant prescribing. Non-Hispanic white patients were more likely to be prescribed antidepressants compared to Hispanic patients (OR = 1.52, 95% CI 1.24-1.87). Physicians' choice on antidepressant varied across with patient age and health insurance status. Compared to private insurance, patients who were primarily covered by Medicare were less likely to be prescribed only SSRIs/SNRIs or other newer antidepressants (RRRs = 0.42 and 0.39; 95% CIs 0.21-0.83 and 0.18-0.84, respectively). We observed strong associations between sociological factors and physicians' antidepressant prescribing patterns. Possible health disparities and gaps between optimal and suboptimal healthcare for patient mental health caused by systematic differences in sociological factors need to be mitigated. We need policy makers to design effective policy interventions to improve physician practice guidelines adherence to eliminate possible variations among physician practices.

Encouraging results in older patients receiving chemotherapy: A retrospective analysis of treatment guideline adherence in daily practice

A retrospective study was performed to determine whether patients over 60 years old who received chemotherapy were treated according to the existing treatment guidelines and to investigate the reasons for dose reductions or treatment delay. Three hundred and seven patients aged over 60 years old and diagnosed with colon, breast or lung cancer between 1998 and 2008 who were treated with chemotherapy in the Radboud University Medical Center were included. From the medical records we recorded the number of and the reasons for dose reductions and delays. We calculated the relative dose intensity (RDI) received. RDI did not decrease significantly with age. However patients over 65 years of age had a higher probability of receiving a suboptimal dose intensity, even when treated with curative intent. There was no correlation between toxicity and age, however the comorbidity score increased with age. The average received RDI was higher in patients diagnosed more recently. Despite increased comorbidity, older patients receiving chemotherapy were generally treated according to protocol without high incidence of severe toxicity. We saw improvement of RDI over the time period investigated. The participation of geriatricians in multidisciplinary oncology teams could help to optimize therapy decisions for patients with comorbidity.

Barriers to clinical practice guidelines adherence in the community oncology setting.

e19687 Background: Clinical practice guidelines (CPGs) are an important information source for physicians as they integrate evidence into routine clinical care. However, the use of CPGs may vary by physician and specialty. Methods: The Association of Community Cancer Centers and Avalere Health designed a survey to identify how community oncologists use CPGs, focusing on: physicians’ perceptions of guidelines, which guidelines they follow, and barriers to guideline adherence. The online survey contained 45 items and was closed in June 2010. Results were tabulated and analyzed. Results: Thirty-six physicians from distinct practices responded. Physicians were likely to have more than 25 years experience (74%) and to treat multiple cancer types (47%). The majority worked in community hospitals (56%), cancer clinics (36%), and private practices (28%). Overall, 94% of physicians reported following CPGs, with NCCN (94%) and ASCO (69%) being preferred sources. However, physicians reported barriers to following CPGs in nearly one fifth (16%) of patient cases. Important barriers included limited time (44%) and limited access to CPGs at the point of care (39%). Common reasons physicians cited for not following guideline recommendations was that they were too rigid for a particular patient (53%) or were not appropriate in a given clinical situation (62%). Notably, the majority of physicians (94%) reported that their practices have created their own guidelines or protocols at times, with one quarter (25%) doing so regularly. Conclusions: Despite agreeing that CPGs are important for delivering high quality patient care, physicians report barriers to CPG adherence and do not consider recommendations appropriate for all patients. Furthermore, many practices are creating their own CPGs, which may undermine a fundamental reason for CPGs: increased standardization of care. Further research on individual physician and practice-level deviation from established CPGs is needed.

Diabetes Management in the Nursing Home

Diabetes mellitus is a disease with debilitating potential. Growing numbers of elderly individuals are being admitted to under-resourced nursing homes with this often complicated, time-intensive, and costly diagnosis. The purpose of this systematic review of the literature was to determine the trends in diabetes management in nursing homes over the last decade including the use of clinical practice guidelines and the evaluation of management outcomes. Ten medical, nursing, psychological, legal, and business databases were searched for articles written in English between 2000 and 2010 addressing diabetes management in nursing homes or long-term care settings. They were analyzed to determine diabetes management characteristics, use of clinical practice guidelines, resident outcomes associated with different regimens, and implications for improved management and outcomes. A total of 20 studies from 6 countries, primarily the United States, including both qualitative and quantitative designs and a combined sample of 779,707 residents, met the inclusion criteria. The majority of the studies described frequencies of various management practices and found rare clinical practice guideline adherence. A severe lack of research relating management practices to health and quality-of-life outcomes was evident as was a lack of the voice of the resident in determining the diabetes regimen. Clear implications were found for improvement in diabetes management education for residents, families, and all health care providers in this setting.

Knowledge, attitudes and behaviours associated with the provision of hepatitis C care by Canadian family physicians

The role of primary care physicians in providing care for hepatitis C virus (HCV) infection is increasingly emphasized, but many gaps and challenges remain. This study explores family physicians' knowledge, attitudes and practices associated with providing care for HCV infection. Seven hundred and forty-nine members of the College of Family Physicians of Canada (CFPC) completed a self-administered survey examining knowledge, attitudes and behaviours regarding HCV infection screening and care. Multivariate analyses were performed using the outcome, HCV care provision, and variables based on a conceptual model of practice guideline adherence. Family physicians providing basic-advanced HCV care were more likely to be older, practice in a rural setting, have injection drug users (IDU) in their practice and have higher levels of knowledge about the initial assessment (OR = 1.77; 95% CI = 1.23-2.54) and treatment of HCV (OR = 1.74; 95% CI = 1.24-2.43). They were also less likely to believe that family physicians do not have a role in HCV care (OR = 0.41; 95% CI = 0.30-0.58). Educational programmes should target physicians less likely to provide HCV care, namely family physicians practicing in urban areas and those who do not care for any IDU patients. Training and continuing medical education programmes that aim to shift family physicians' attitudes about the provision of HCV care by promoting their roles as integral to HCV care could contribute to easing the burden on consultant physicians and lead to improved access to treatment for HCV infection.

Practice guideline adherence and health care outcomes – use of prophylactic antibiotics during surgery in Taiwan

To evaluate adherence to guidelines for prophylactic antibiotic use in total knee replacement (TKR) and total hip replacement (THR) procedures and to examine the associations between guideline adherence and health care outcomes. Using nationwide health insurance claims data, all adult inpatients undergoing TKR or THR procedures at teaching hospitals from 2002 to 2006, were included. Guideline adherence rates were assessed every year according to the national guidelines introduced in 2004. Multiple regression analyses with generalized estimating equations models were used to examine the relationships between the deliberate variables. The guideline adherence rates stably increased from 14.07% in 2002 to 28.34% in 2006. The 2006 dataset included 12 863 observations. The results revealed that guideline adherence was negatively associated with length of stay and health care expenses with beta = -0.0207 and -0.0087, respectively (P < 0.0001). The 30-day readmission rate was 1.54% among the patients seen in 2006, and it was significantly different between the two groups, with 0.90% of the adherence group and 1.82% of the non-adherence group being readmitted (P = 0.0002). The guideline adherence for prophylactic use of antibiotics is improving in Taiwan and is associated with a shorter length of stay, fewer medical expenses and lower 30-day readmission rates. Promoting evidence-based practice guidelines may be beneficial to patients and health care providers.

Practice Patterns and Guideline Adherence of Medical Oncologists in Managing Patients with Early Breast Cancer

Studies of adherence to breast cancer guidelines have often focused on primary therapies, but concordance with other guideline recommendations has not been examined as extensively. This study assesses the knowledge and practice patterns of medical oncologists in the United States to inform education and quality improvement initiatives that can improve breast cancer care. A survey containing case vignettes and related questions was developed to examine oncologists' clinical decision-making in evaluating and treating women with early breast cancer. The instrument was distributed to a random sample of 742 oncologists in the United States and yielded 205 responses (27.6% response rate). Responses from 184 practicing medical oncologists were analyzed relative to the 2007 NCCN Clinical Practice Guidelines in Oncology: Breast Cancer. Most oncologists made guideline-consistent choices in clarifying indeterminate human epidermal growth factor 2 (HER2) status (85%), initial treatment for early breast cancer (95%), and postsurgical management of locally advanced breast cancer (82%). Guideline-discordant choices were seen in the lack of clip placement before neoadjuvant chemotherapy (36%), unnecessary use of PET scanning for initial assessment (34%), inappropriate assessment of menopausal status (33%), inappropriate use of tumor markers (22%), and use of chest imaging (16%) during posttherapeutic surveillance. Oncologists often make guideline-consistent choices, but discordant clinical decisions may occur in important aspects of care for early breast cancer. Broadening the diffusion and adoption of guideline recommendations is an important mechanism for addressing these gaps and may substantially improve the quality of breast cancer care.

Improving patient safety using clinical needs assessments in IV therapy

A clinical needs assessment (CNA) consulting programme was initiated with the NHS Healthcare Purchasing Consortium to improve safety and reduce risk in intravenous (IV) therapy through standardization, best practice guideline adherence and ensuring adequate training. The results of CNAs conducted at two acute NHS Trusts (A and B) are summarized. Fifteen-minute 'pump needs assessment' and 'clinical practice review' interviews were conducted with junior and senior staff members, and recommendations were made to a multidisciplinary Trust-steering committee. Post-assessment recommendations included: standardizing to one pump type with activated medication error reduction software, purchasing optimal numbers of IV pumps, implementing best practice guidelines and protocols to minimize unnecessary IV set tear-down (removing and replacing IV set), the use of standardized accessories and ensuring adequate training. Both assessments showed that streamlining, best practice adherence and training could result in pronounced cost savings and improve patient safety. Importantly, the cost savings could facilitate implementation of CNA recommendations. The Trusts have since prioritized standardizing IV pumps and accessories and future implementation of medication error software. The CNA is a valuable tool for Trusts that positively impacts on patient safety.

Improved guideline adherence to pharmacotherapy of chronic systolic heart failure in general practice – results from a cluster‐randomized controlled trial of implementation of a clinical practice guideline

Clinical practice guidelines (CPG) reflect the evidence of effective pharmacotherapy of chronic (systolic) heart failure (CHF) which needs to be implemented. This study aimed to evaluate the effect of a new, multifaceted intervention (educational train-the-trainer course plus pharmacotherapy feedback = TTT) compared with standard education on guideline adherence (GA) in general practice. Thirty-seven participating general practitioners (GPs) were randomized (18 vs. 19) and included 168 patients with ascertained symptomatic CHF [New York Heart Association (NYHA) II-IV]. Groups received CPG, the TTT intervention consisted of four interactive educational meetings and a pharmacotherapy feedback, while the control group received a usual lecture (Standard). Outcome measure was GA assessed by prescription rates and target dosing of angiotensin converting enzyme (ACE) inhibitors (ACE-I) or angiotensin receptor blockers (ARB), beta-blockers (BB) and aldosterone antagonists (AA) at baseline and 7-month follow-up. Group comparisons at follow-up were adjusted to GA, sex, age and NYHA stage at baseline. Prescription rates at baseline (n = 168) were high (ACE-I/ARB 90, BB 79 and AA 29%) in both groups. At follow up (n = 146), TTT improved compared with Standard regarding AA (43% vs. 23%, P = 0.04) and the rates of reached target doses of ACE-I/ARB (28% vs. 15%, P = 0.04). TTT group achieved significantly higher mean percentages of daily target dose (52% vs. 42%, mean difference 10.3%, 95% CI 0.84-19.8, P = 0.03). Despite of pre-existing high GA in both groups and an active control group, the multifaceted intervention was effective in quality of care measured by GA. Further research is needed on the choice of interventions in different provider populations.

Variations in Practice Guideline Adherence for Abnormal Cervical Cytology in a County Healthcare System

Reduction in cervical cancer incidence and mortality is not only dependant on promoting cervical cancer screening but also on providing appropriate follow-up and treatment of abnormal cervical cytology. The objective of this study was to determine variations in guideline adherence for women requiring abnormal cervical cytology follow-up. Subjects of the study are women 18 years or older with an abnormal Pap test in 2000 within a large county healthcare system (n = 8,571). Guideline adherence was determined by the presence or absence of the appropriate follow-up procedure within an acceptable time interval for each degree of cytological abnormality. Patients with no follow-up studies were deemed to be lost to follow-up. Of study subjects, 18.5% were lost to follow-up care. Of the remaining 6,987 women, 60.3% received optimal care, 9.4% received suboptimal care, and 30.3% received poor care. Follow-up rates were higher for patients with higher degree of cytological abnormality (OR, 1.29, 95% CI, 1.17-1.42), older patients (OR, 1.03, 95% CI, 1.02-1.030) and those receiving the index Pap test at a larger healthcare facility (OR, 1.13; 95% CI, 1.01-1.27). Receiving optimal care was positively correlated with higher degree of cytological abnormality (p < .0001) and larger facility size (p = .002). Regional variations in care demonstrated the largest cluster having the lowest lost to follow-up rate and the most optimal care. A significant number of women with abnormal cervical cytology are receiving less than optimal care. Further studies are required to determine the specific healthcare delivery practices that need to be targeted to improve guideline adherence for follow-up of abnormal cytology.

Delivery patterns of recommended chronic kidney disease care in clinical practice: administrative claims-based analysis and systematic literature review

Clinical practice guidelines for management of chronic kidney disease (CKD) have been developed within the Kidney Disease Outcomes Quality Initiative (K/DOQI). Adherence patterns may identify focus areas for quality improvement. We retrospectively studied contemporary CKD care patterns within a private health system in the United States, and systematically reviewed literature of reported practices internationally. Five hundred and nineteen patients with moderate CKD (estimated GFR 30-59 ml/min) using healthcare benefits in 2002-2005 were identified from administrative insurance records. Thirty-three relevant publications in 2000-2006 describing care in 77,588 CKD patients were reviewed. Baseline demographic traits and provider specialty were considered as correlates of delivered care. Testing consistent with K/DOQI guidelines and prevalence of angiotensin converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARB) medication prescriptions were ascertained from billing claims. Care descriptions in the literature sample were based on medical charts, electronic records and/or claims. KDOQI-consistent measurements of parathyroid hormone (7.1 vs. 0.6%, P = 0.0002), phosphorus (38.2 vs. 1.9%, P < 0.0001) and quantified urinary protein (23.8 vs. 9.4%, P = 0.008) were more common among CKD patients with versus without nephrology referral in the administrative data. Nephrology referral correlated with increased likelihood of testing for parathyroid hormone and phosphorus after adjustment for baseline patient factors. Use of ACEi/ARB medications was more common among patients with nephrology contact (50.0 vs. 30.0%; P = 0.008) but appeared largely driven by higher comorbidity burden. The literature review demonstrated similar practice patterns. Delivery of CKD care may be monitored by administrative data. There is opportunity for improvement in CKD guideline adherence in practice.

Anticoagulation treatment for the reduction of stroke in atrial fibrillation: a cohort study to examine the gap between guidelines and routine medical practice

Atrial fibrillation (AF) is the most common heart arrhythmia, affecting 6% of people over 65 years, and carries a 4.5% average annual stroke risk, which can be reduced by appropriate anticoagulation. A multi-centre observational study, Management and Outcomes in the Care of Atrial fibrillation in Germany (MOCA) was conducted to evaluate the current anticoagulation treatment pattern in patients with AF in Germany. Patients with AF were recruited from December 2003 to June 2004 in physician practices. Clinical data including International Normalised Ratio (INR) values and anticoagulation strategy were obtained from the physician chart and the patient follow-up, documenting hospitalisations, medications, and complications, was conducted at three and six months. Main outcome measures included anticoagulation methods, practice guidelines adherence and time within recommended anticoagulation range. 361 patients with AF (mean age 71+/-9, 61% male) were recruited in 45 physician practices. 90% of all patients had been treated with Vitamin K-Antagonists (VKA) at some time since AF-diagnosis, 88% were still treated. 10% of patients received aspirin as their anticoagulation therapy. Monitoring occurred at least once a month in over 70% of patients. Monitored INR values were 56% of the time within, 14% below and 30% over the recommended target range. A gap of 40% existed between the guideline recommendations and actual practice. Younger patients (<60 years of age) with no documented risk factors for stroke were over-treated with VKAs and patients older than 75 years without contraindications for anticoagulation were under-treated. This study presents 'real-life' data in treating patients with AF in Germany and identifies the potential to advance the quality of care with respect to anticoagulation.

Audit and feedback and clinical practice guideline adherence: making feedback actionable.

BackgroundAs a strategy for improving clinical practice guideline (CPG) adherence, audit and feedback (A&F) has been found to be variably effective, yet A&F research has not investigated the impact of feedback characteristics on its effectiveness. This paper explores how high performing facilities (HPF) and low performing facilities (LPF) differ in the way they use clinical audit data for feedback purposes.MethodDescriptive, qualitative, cross-sectional study of a purposeful sample of six Veterans Affairs Medical Centers (VAMCs) with high and low adherence to six CPGs, as measured by external chart review audits.One-hundred and two employees involved with outpatient CPG implementation across the six facilities participated in one-hour semi-structured interviews where they discussed strategies, facilitators and barriers to implementing CPGs. Interviews were analyzed using techniques from the grounded theory method.ResultsHigh performers provided timely, individualized, non-punitive feedback to providers, whereas low performers were more variable in their timeliness and non-punitiveness and relied on more standardized, facility-level reports. The concept of actionable feedback emerged as the core category from the data, around which timeliness, individualization, non-punitiveness, and customizability can be hierarchically ordered.ConclusionFacilities with a successful record of guideline adherence tend to deliver more timely, individualized and non-punitive feedback to providers about their adherence than facilities with a poor record of guideline adherence. Consistent with findings from organizational research, feedback intervention characteristics may influence the feedback's effectiveness at changing desired behaviors.

Organizational and provider characteristics fostering smoking cessation practice guideline adherence: an empirical look.

We examined the relationship between physician adherence with a smoking cessation guideline and organizational structures, policies, leadership support, and physician knowledge and attitudes. A random sample of 844 physicians practicing in 127 VHA hospitals was surveyed. Survey results were aggregated to the hospital level and linked with data on organizational characteristics from the 1998 annual survey of hospitals by the American Hospital Association. Significant predictors of adherence included organizational policies related to nicotine replacement prescriptions, the timing and effectiveness of guideline implementation, physicians' knowledge of VHA clinical guidelines generally, and physicians' beliefs about the receptiveness of patients to smoking cessation.