Evaluation of physician preferences for guideline implementation

Algorithms for personalized therapy of type 2 diabetes: results of a web-based international survey

OBJECTIVE

In recent years increasing interest in the issue of treatment personalization for type 2 diabetes (T2DM) has emerged. This international web-based survey aimed to evaluate opinions of physicians about tailored therapeutic algorithms developed by the Italian Association of Diabetologists (AMD) and available online, and to get suggestions for future developments. Another aim of this initiative was to assess whether the online advertising and the survey would have increased the global visibility of the AMD algorithms.

RESEARCH DESIGN AND METHODS

The web-based survey, which comprised five questions, has been available from the homepage of the web-version of the journal Diabetes Care throughout the month of December 2013, and on the AMD website between December 2013 and September 2014. Participation was totally free and responders were anonymous.

RESULTS

Overall, 452 physicians (M=58.4%) participated in the survey. Diabetologists accounted for 76.8% of responders. The results of the survey show wide agreement (>90%) by participants on the utility of the algorithms proposed, even if they do not cover all possible needs of patients with T2DM for a personalized therapeutic approach. In the online survey period and in the months after its conclusion, a relevant and durable increase in the number of unique users who visited the websites was registered, compared to the period preceding the survey.

CONCLUSIONS

Patients with T2DM are heterogeneous, and there is interest toward accessible and easy to use personalized therapeutic algorithms. Responders opinions probably reflect the peculiar organization of diabetes care in each country.

Personalized therapy algorithms for type 2 diabetes: a phenotype-based approach

Type 2 diabetes is a progressive disease with a complex and multifactorial pathophysiology. Patients with type 2 diabetes show a variety of clinical features, including different “phenotypes” of hyperglycemia (eg, fasting/preprandial or postprandial). Thus, the best treatment choice is sometimes difficult to make, and treatment initiation or optimization is postponed. This situation may explain why, despite the existing complex therapeutic armamentarium and guidelines for the treatment of type 2 diabetes, a significant proportion of patients do not have good metabolic control and at risk of developing the late complications of diabetes. The Italian Association of Medical Diabetologists has developed an innovative personalized algorithm for the treatment of type 2 diabetes, which is available online. According to the main features shown by the patient, six algorithms are proposed, according to glycated hemoglobin (HbA_1c, ≥9% or ≤9%), body mass index (≤30 kg/m² or ≥30 kg/m²), occupational risk potentially related to hypoglycemia, chronic renal failure, and frail elderly status. Through self-monitoring of blood glucose, patients are phenotyped according to the occurrence of fasting/preprandial or postprandial hyperglycemia. In each of these six algorithms, the gradual choice of treatment is related to the identified phenotype. With one exception, these algorithms contain a stepwise approach for patients with type 2 diabetes who are metformin-intolerant. The glycemic targets (HbA_1c, fasting/preprandial and postprandial glycemia) are also personalized. This accessible and easy to use algorithm may help physicians to choose a personalized treatment plan for each patient and to optimize it in a timely manner, thereby lessening clinical inertia.

Assessing physician utilization of laboratory practice guidelines: barriers and opportunities for improvement

OBJECTIVES

To assess physician utilization of laboratory practice guidelines (LPGs)³ to improve LPG uptake and use.

DESIGN AND METHODS

A statewide survey of 4987 primary care physicians (PCPs) and 75 infectious disease (ID) specialists was conducted in 2005-2006 to correlate guideline source with users' awareness, utilization, and perceived usefulness of LPGs. We compared LPGs developed by the Centers for Disease Control and Prevention (CDC) to LPGs developed by the Washington State Department of Health through its Clinical Laboratory Advisory Council (CLAC).

RESULTS

Physician awareness of LPGs was a major impediment to utilization of CLAC LPGs, and they were perceived as inaccessible, too numerous and unhelpful. However, once aware, respondents tended to use LPGs and there were no important differences in impediments or the ways CDC and CLAC LPGs were used. Of the PCPs who had a computerized physician order entry system (CPOE), a majority (92%) found, or expected that they would find, the integration of guidelines into their system helpful.

CONCLUSIONS

For both CDC and CLAC LPGs, the greatest impediments to uptake were awareness and familiarity, which depended upon LPG source, physician specialty, and practice setting. There was no apparent impediment to uptake of CLAC or CDC LPGs based upon their credibility. Because better promotion could increase uptake, CLAC LPGs are now promoted by the Washington State Medical Association. Integration of LPGs into CPOE and smart phone applications could address major impediments to clinician use. The Cabana paradigm would be useful for any organization seeking to improve LPG impact.

Do guidelines influence medical practice? Changes in management of acute pancreatitis 7 years after the publication of the French guidelines

OBJECTIVES

The elaboration and publication of guidelines should help homogenizing the management of frequent diseases with high mortality and morbidity rates, such as acute pancreatitis.

AIM

To evaluate the implementation of French guidelines on the management of acute pancreatitis (AP), and to correlate changes with a received medical training course.

METHODS

In 2001 (before the Consensus Conference) and 2008, the same questionnaire dealing with recommendations for AP management was sent to the French gastroenterology Units. Responses in 2001 and 2008 were compared.

RESULTS

One hundred and seventy-six questionnaires were analyzed (public hospitals: 62%, academic hospitals: 20%, private institutions: 18%). In 2008 (vs. 2001), lipase levels were measured for establishing AP diagnosis by 99% (vs. 83%). To evaluate AP severity, a computed tomography (CT) scan was performed at 48 h by 69% (vs. 29%, P ≤ 0.001). The most used severity index was the CT Balthazar score 76% (vs. 55%, P ≤ 0.001). Antibiotic prophylaxis and artificial nutrition by enteral route were proposed by 20% (vs. 57%) and 58% (vs. 25%) for necrotizing pancreatitis. Practices were more frequently in agreement with the guidelines in public nonacademic and academic hospitals. Training course on AP management was associated with a more appropriate use of CT scan for the evaluation of AP severity and of antibiotics.

CONCLUSION

Major changes were noticed since the publication of the French guidelines. Although establishing guidelines is an expensive process, it does increase compliance with best evidence-based practice.

Educational and decision-support tools for asthma-management guideline implementation

Many international and national asthma guidelines are now available in large parts of the world, but they are not yet implemented appropriately. There is a gap between scientific evidence-based medicine and real clinical practice. Implementation of guidelines is highly complex. Special strategies are needed to encourage guideline-based, high-quality care. It is important to understand the contents, the format, and the learning strategies which physicians prefer for the dissemination of guidelines. Physicians prefer more concise and immediately available guidelines that are practical to use. Thus, asthma guidelines should be disseminated as convenient and easily accessible tools. Various education programs and decision-support tools have been designed and applied to the clinical management of asthma to solve these challenging problems. Many of them have been shown to be effective at increasing physicians' knowledge and adherence to asthma guidelines and improving patients' clinical outcomes. These educational and decision-support tools are expected to contribute to a narrowing of the gap between asthma guidelines and practice/implementation of the guidelines.

Physicians' preferences for asthma guidelines implementation

Purpose

Patient care based on asthma guidelines is cost-effective and leads to improved treatment outcomes. However, ineffective implementation strategies interfere with the use of these recommendations in clinical practice. This study investigated physicians' preferences for asthma guidelines, including content, supporting evidence, learning strategies, format, and placement in the clinical workplace.

Methods

We obtained information through a questionnaire survey. The questionnaire was distributed to physicians attending continuing medical education courses and sent to other physicians by airmail, e-mail, and facsimile.

Results

A total of 183 physicians responded (male to female ratio, 2.3:1; mean age, 40.4±9.9 years); 89.9% of respondents were internists or pediatricians, and 51.7% were primary care physicians. Physicians preferred information that described asthma medications, classified the disease according to severity and level of control, and provided methods of evaluation/treatment/monitoring and management of acute exacerbation. The most effective strategies for encouraging the use of the guidelines were through continuing medical education and discussions with colleagues. Physicians required supporting evidence in the form of randomized controlled trials and expert consensus. They preferred that the guidelines be presented as algorithms or flow charts/flow diagrams on plastic sheets, pocket cards, or in electronic medical records.

Conclusions

This study identified the items of the asthma guidelines preferred by physicians in Korea. Asthma guidelines with physicians' preferences would encourage their implementation in clinical practice.

Implementing arthritis clinical practice guidelines in primary care

BACKGROUND

Multi-faceted interventions are among the strongest methods for changing provider behavior.

AIMS

This paper reports the design, implementation and process evaluation of an educational program to disseminate clinical practice guidelines (CPGs) on the management of rheumatoid arthritis (RA) and osteoarthritis (OA) in primary care.

METHODS

Organizations were invited to participate in inter-professional workshops on OA and RA followed by six months of activities to support the delivery of care in the community. Confidence in ability to manage arthritis was assessed at baseline using a 10 point numerical rating scale. Qualitative assessments were done immediately and 3-12 months post workshop.

RESULTS

646 multidisciplinary providers from 216 organizations attended one of 30 workshops. Providers (n = 584) reported moderate confidence in managing arthritis: family physicians: mean: SD = 7.46(1.42), n = 145; nurse practitioners: 6.10(1.84), n = 73; other health care professionals: 5.23(2.83), n = 389. Participants identified team learning, the opportunity to network and the involvement of trained patient educators as strong features of the workshops. At follow-up, participants indicated the greatest impact of the program was on collaborative care (83%) and patient self-management (79%).

CONCLUSIONS

Qualitative results suggest that inter-professional learning may be a successful strategy for improving the delivery of collaborative arthritis care and supporting patient self-management.

Improved cardiovascular prevention using best CME practices: a randomized trial

INTRODUCTION

It was hypothesized that after a continuing medical education (CME) event, practice enablers and reinforcers addressing main clinical barriers to preventive care would be more effective in improving general practitioners' (GPs) adherence to cardiovascular guidelines than a CME event only.

METHODS

A cluster-randomized trial was conducted on a convenience sample of 122 GPs who were randomly assigned to either CME only (control group) or CME with practice enablers and reinforcers (PER group). In the PER group, nurses visited GPs' offices once a month to implement the clinical intervention on patients > or = 55 years old with a scheduled visit in the month following the nurse visit: (1) screening medical records for potentially undermanaged high-risk patients; (2) prompting physicians to reassess preventive care in these patients; (3) enclosing a checklist reporting most recent information relevant to guidelines' implementation; and (4) enclosing a summary of experts' recommendations in the form of a follow-up and treatment algorithm.

RESULTS

A retrospective chart audit of 2344 consenting patients, potentially undermanaged at baseline, demonstrated that the PER intervention following CME significantly improved adherence to guidelines compared to CME alone (OR: 1.78, 95% CI: 1.32-2.41).

DISCUSSION

The intervention was designed for self-implementation in primary care practices that have their own nursing staff. PER GPs were highly satisfied with the intervention; the majority said that they would implement it in their practice if someone trained their nurse, thus suggesting support for development of a multiprofessional CME program to disseminate this clinical approach to primary care practice groups.

Guideline attribute and implementation preferences among physicians in multiple health systems

OBJECTIVES

Although practice guidelines are effective in assisting providers with clinical decision making, ineffective implementation strategies often prevent their use in practice. This study aimed to understand physician preferences for guideline format, placement, content, evidence, and learning strategies in different clinical environments.

SUBJECTS AND METHODS

Semistructured telephone interviews were conducted with 500 randomly selected physicians from 4 major US health systems who were involved in the treatment of patients with acute myocardial infarction or pediatric asthma. Paired sample t tests and Tukey's method of comparisons determined the relative ranking of physicians' guideline implementation preferences.

RESULTS

Physicians preferred guidelines located on the front of the patient chart, in palm pilots, or in progress notes and presented as flow charts/flow diagrams, algorithms, or preprinted orders that contain strategies to minimize readmits/encourage self-management and immediate treatment flows. Discussions with colleagues and continuing medical education are the most effective strategies for encouraging guideline use, and randomized controlled trials remain the most persuasive medical evidence.

CONCLUSIONS

Health care organizations must align guideline implementation efforts with physician preferences to encourage utilization. The results of this study reveal systematic physician preferences for guideline implementation that can be applied to clinical settings to encourage guideline use by physicians.

Solving the information overload problem: a letter from Canada

Doctors are inundated with medical information, some inadequately evidence-based, much of it captured in clinical practice guidelines (CPGs). The Ontario Guidelines Advisory Committee (GAC) selects topic areas, searches for all CPGs on the topic, and reviews them using the AGREE Instrument. Based in large part on the AGREE score, the GAC summarises one guideline in each topic area and mounts it on its website, with links to other information (eg, clinical algorithms) where possible. Two topic areas have been selected for implementation--the reduction of unnecessary preoperative testing and the rational management of acute low back pain. Implementation strategies include performance feedback, training of opinion leaders, development of algorithms and reminders, and communication through journals and continuing medical education activities.

Can prescription refill feedback to physicians improve patient adherence?

BACKGROUND

Although adherence to long-term drug therapy is an important issue, the means to facilitate its assessment and improvement in clinical practice remain a challenge.

OBJECTIVE

To evaluate the impact of prescription refill feedback and adherence education provided to primary care physicians.

METHODS

We provided 83 resident and attending physicians at a university-based general internal medicine practice with refill adherence reports on each of 340 diabetic patients. An educational session on adherence assessment and improvement techniques was held, and all physicians received a written outline on this topic. Physician attitude toward the intervention and 6-month change in refill adherence (doses filled/doses prescribed) of their patient panels were assessed. A nonrandomized comparison group of patients receiving hypertension medications for whom the physicians did not receive feedback was also evaluated.

RESULTS

The overall improvement in mean refill adherence was not significant (83.9% vs 86.0%, P=0.18). The educational session was attended by 53% of the physicians. The patient refill adherence of physicians attending the educational session improved by 5.0% (P<0.0009) with no significant change among patients of physicians not attending the session. There was no adherence change among patients for whom physicians did not receive refill feedback data, regardless of educational session attendance.

CONCLUSIONS

Patients of physicians that received refill feedback and attended an educational session improved their refill adherence. After replication of these results in a randomized trial, broad implementation of this approach could have substantial impact from a public health perspective, given the ubiquity of prescription claims data.

Paracetamol overdose: an evidence based flowchart to guide management

A flowchart for the management of patients with paracetamol poisoning is presented to help clinicians in the emergency department.

The sustained impact of an evidenced-based clinical pathway for acute appendicitis

Appendicitis is a frequent pediatric surgical condition for which there is great variability among practitioners regarding diagnosis and postoperative management. With this in mind, the authors designed and implemented an evidence-based appendicitis clinical pathway at their institution. Establishment of the pathway resulted in decreased hospital cost, reduced hospital stay, and fewer unnecessary laboratory tests. The purpose of the current study was to determine the sustainability of the pathway beyond its initial implementation phase. The authors showed that several, but not all, favorable outcomes of the pathway were sustained. These data suggest that a clinical pathway for appendicitis at the authors' institution results in sustained beneficial effects in some but not all outcome parameters. Ongoing monitoring of pathway compliance, continued education of practitioners and nursing personnel, and identification of key pathway team member(s) responsible for the pathway system might result in a greater long-term impact of these guidelines.

Improving blood pressure control in diabetes: limitations of a clinical reminder in influencing physician behavior

INTRODUCTION

Hypertension should be aggressively treated, especially in diabetic patients. But studies of physician prescribing habits reveal that physicians often delay making medication changes or initiating antihypertensive therapy. A chart-based reminder was designed to improve physician medication prescribing in this clinical situation.

METHODS

A randomized controlled trial was conducted at the Veterans Affairs Medical Center in Richmond, Virginia. Patients with diabetes and hypertension were selected. A highly visible chart reminder was applied to the front of outpatient charts in the intervention group practice. A chart review was conducted to assess physician-directed medication changes. A successful outcome was defined as any antihypertensive medication increase or addition at that same visit.

RESULTS

Physicians were more likely to intensify antihypertensive medication as the blood pressure increased regardless of the reminder. Overall, only 33% of visits resulted in a medication change, even though 93% of patients had elevations over target blood pressure at the follow-up visit. Physicians in the intervention and control groups made changes to medication at similar rates (chi 2 = 0.621, p = .511).

DISCUSSION

In this study, a chart reminder failed to improve physician compliance with the clinical guideline for hypertension management in diabetics, Sixth Report of the Joint National Committee on the Detection, Evaluation, Prevention and Treatment of High Blood Pressure. To inform the design of effective intervention strategies, further research should explore specific barriers to guideline adherence in this clinical situation.

Implementing practice guidelines for depression: applying a new framework to an old problem

We discuss the challenges of implementing clinical practice guidelines for depression in the primary care setting. Multiple potential barriers can limit physician guideline adherence and translation of research into improved patient outcomes. Six primary barriers relate to providers (lack of awareness, lack of familiarity, lack of agreement, lack of self efficacy, lack of outcome expectancy, and inertia of previous practice). In addition, factors related to patient, guideline, and practice environment factors encompass external barriers to adherence. By delineating the underlying barriers to adherence, different interventions that are tailored to improve physician adherence to guidelines can be utilized. We review examples of these barriers, as well as interventions to improve guideline adherence. We also review characteristics of successful interventions to improve physician adherence to guidelines for depression. Since different physicians and practice settings may encounter a variety of barriers, multifaceted interventions that are not focused exclusively on the physician tend to be most effective.

Provider adherence to a clinical practice guideline for acute asthma in a pediatric emergency department

Critics of the use of clinical practice guidelines (CPGs) in an emergency department (ED) setting believe that they are too cumbersome and time-consuming, but to the best of the authors' knowledge, potential barriers to CPG adherence in the ED have not been prospectively evaluated.

OBJECTIVES

To measure provider adherence to an ED CPG based on National Asthma Education and Prevention Program (NAEPP) recommendations, and to determine factors associated with provider nonadherence.

METHODS

Prospective, cohort study of children aged 1-18 years with the diagnosis of an acute exacerbation of asthma who were seen in a pediatric ED and requiring admission, as well as a random selection of children discharged to home following pediatric ED care. The following adherence parameters were assessed: at least three nebulized albuterol treatments in the first hour; early steroid administration (after the first nebulizer treatment); clinical assessments using pulse oximetry and peak expiratory flow (PEF) (for children >6 years old); and use of a clinical score to assess acute illness severity (Asthma Severity Score). Nonadherence was defined as any deviation of the above parameters.

RESULTS

Between July 1, 1998, and June 30, 1999, 369 patients were studied. Of these, 38% (139) were discharged to home, 38% (140) were admitted to the observation unit, and 24% (90) were admitted to the inpatient unit. Illness severities at initial presentation to the ED were: 24% (86) had mild exacerbations, 59% (212) had moderate exacerbations, and 17% (62) had severe exacerbations. Sixty-eight percent (95% CI = 63% to 73%) of the patients were managed with complete adherence to the CPG. Of the 32% with some form of nonadherence, most (63%) were children older than 6 years; in this group 64% (48/75) were nonadherent due to lack of PEF assessment. When PEF assessment was disregarded, an 83% (95% CI = 79% to 87%) adherence to the CPG was achieved. Other nonadherence factors included: lack of at least three nebulized albuterol treatments provided timely within the first hour (5%); delay in steroid administration (6%); lack of pulse oximeter use (0.5%); and failure to record clinical score to assess severity (1.1%). Patient age, illness severity (acute and chronic), first episode of wheezing, and high ED volume periods (evenings and weekends) did not worsen adherence.

CONCLUSIONS

Clinical practice guidelines can be used successfully in the pediatric ED and provide a more efficient management and treatment approach to acute exacerbations of childhood asthma. With a systematic and concise CPG, barriers to adherence in a pediatric ED appear to be minimal, with the exception of using PEF in the routine ED assessment.

Enhancing outcomes: guidelines, standards, and protocols

Guidelines, protocols, and standards have gained attention as clinical tools designed to enhance clinical decision-making and practice. Yet, evidence has emerged that clinicians are having difficulty integrating new knowledge presented by these tools into practice. This article explores the benefits and barriers to using guidelines and protocols, probes the issues of producing these tools, and examines processes that are critical to constructing valid tools. The key functions important in successful development and implementation of guidelines and protocols are presented, as well as the direction these clinical adjuncts will take in the future.