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Adherence, Not Just for Patients: Comment on “Low Back Pain and Best Practice Care”

Adherence, Not Just for Patients: Comment on “Low Back Pain and Best Practice Care” Despite good intentions, patients do not always follow “doctor's orders.” It turns out that physicians are not much better, at least when it comes to adherence to clinical practice guidelines. Williams and coauthors present another compelling example. They analyzed 3533 patient visits to Australian general practitioners during the 3 years before and the 3 years after the publication of a clinical practice guideline for the treatment of low back pain.1 The introduction of a local, evidence-based clinical practice guideline had no effect on physician treatment of low back pain as measured by the frequency of patient counseling, prescription of analgesics, and use of imaging. These results are not an isolated finding. Less-than-optimal rates of physician adherence to back pain guidelines have been noted in the United States, Sweden, and Ireland.2-4 A systematic review of physician guideline adherence published a decade ago found that no specialty, practice location, or guideline topic is exempt from this observation.5 Given that clinical practice guidelines can lead to higher-quality care at a more predictable cost, how can we promote their use? Perhaps we should start by asking whose responsibility is it to ensure physician adherence to these guidelines. The definition of professionalism implies that individual physicians will strive to stay up to date and apply the most current guidelines for providing quality care.6 In addition, self-evaluation of practice performance is now a routine component for maintenance of board certification for physicians in many specialties. However, it is not enough to rely on the best efforts of physicians. There are many well-recognized barriers that prevent adherence, such as competing practice demands and the limited time to apply an increasing number of guideline recommendations.5 Professional organizations and guideline developers need to translate their work into practice. Guideline production is very resource intensive. Organizations and societies that develop clinical practice guidelines are recognizing the need to develop accompanying implementation strategies to increase the likelihood of adoption by end users.7,8 For example, the Bureau of Maternal and Child Health, in collaboration with the American Academy of Pediatrics, recently developed a comprehensive set of pediatric health supervision guidelines.9 In addition to guideline development, an implementation plan was developed to encourage physician adherence by identifying successful practice implementation examples, disseminating those models to stakeholders, and providing technical assistance for implementation. Payment structure can play a role as well. Clinical practice guidelines may be more likely to be adopted if guideline recommendations are consistent with reimbursement arrangements. As a result, the development of evidence-based reimbursement policies by third-party payers may be just as important as the development of evidence-based guidelines. “Pay for performance” initiatives, in which an external payer rewards physicians for quality achievements such as guideline adherence, seem like a natural bridge; however, data on their effectiveness are not yet clear.10 Finally, patients may be helpful in enhancing physician guideline adherence through public education programs or through public reporting programs. However, individual patient preferences about clinical care may not directly match quality clinical practice guideline recommendations. For example, a recent analysis of low rates of guideline adherence for colorectal cancer screening guidelines at one Veteran's Administration hospital found that 47% of cases were unscreened secondary to patient preference.11 In the end, all individual physicians who consider themselves professionals strive to carefully and appropriately apply the most current clinical practice guidelines for their patients. However, to help carry this burden, professional organizations that develop guidelines must take the next step to utilize their sway as opinion leaders to encourage adherence. Guideline developers should identify successful practice models that promote adherence to their guideline recommendations and disseminate those examples. Payers and practice managers need to carefully align incentives with guideline recommendations. Public health practitioners can help creatively harness patient and community knowledge, attitudes, and behaviors to influence and improve physician adherence. In addition, more studies are needed to determine the most effective strategies for implementing clinical practice guidelines. In the end, by leveraging these forces, we can reap the rewards of improved adherence and patient outcomes. Correspondence: Dr Cabana, Division of General Pediatrics, University of California, San Francisco, School of Medicine, 3333 California St, Ste 245, San Francisco, CA 94118 (michael.cabana@ucsf.edu). Financial Disclosure: None reported. Funding/Support: This work was funded by the National Heart, Lung, and Blood Institute (HL70771). References 1. National Health and Medical Research Council, Evidence-Based Management of Acute Musculoskeletal Pain: A Guide for Clinicians. Canberra, Australia NHMRC2004; 2. Jackson JLBrowning R Impact of national low back pain guidelines on clinical practice. South Med J 2005;98 (2) 139- 143PubMedGoogle ScholarCrossref 3. Overmeer TLinton SJHolmquist LEriksson MEngfeldt P Do evidence-based guidelines have an impact in primary care? a cross-sectional study of Swedish physicians and physiotherapists. Spine (Phila Pa 1976) 2005;30 (1) 146- 151PubMedGoogle Scholar 4. Fullen BMMaher TBury GTynan ADaly LEHurley DA Adherence of Irish general practitioners to European guidelines for acute low back pain. Eur J Pain 2007;11 (6) 614- 623PubMedGoogle ScholarCrossref 5. Cabana MDRand CSPowe NR et al. Why don't physicians follow clinical practice guidelines? a framework for improvement. JAMA 1999;282 (15) 1458- 1465PubMedGoogle ScholarCrossref 6. ABIM Foundation; ACP-ASIM Foundation; American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine, Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136 (3) 243- 246PubMedGoogle ScholarCrossref 7. Somerfield MREinhaus KHagerty KLBrouwers MCSeidenfeld JLyman GHAmerican Society of Clinical Oncology, American Society of Clinical Oncology Clinical Practice Guidelines: opportunities and challenges. J Clin Oncol 2008;26 (24) 4022- 4026PubMedGoogle ScholarCrossref 8. Heffner JEAlberts WMIrwin RWunderink R Translating guidelines into clinical practice: recommendations to the American College of Chest Physicians. Chest 2000;118 (2) s70- s73PubMedGoogle ScholarCrossref 9. Hagan JFShaw JSDuncan P Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. Elk Grove Village, IL American Academy of Pediatrics2008; 10. Glickman SWOu FSDelong ER et al. Pay for performance, quality of care, and outcomes in acute myocardial infarction. JAMA 2007;297 (21) 2373- 2380PubMedGoogle ScholarCrossref 11. Walter LCDavidowitz NPHeineken PACovinsky KE Pitfalls of Converting practice guidelines into quality measures: lessons learned from a VA performance measure. JAMA 2004;291 (20) 2466- 2470PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Adherence, Not Just for Patients: Comment on “Low Back Pain and Best Practice Care”

Archives of Internal Medicine , Volume 170 (3) – Feb 8, 2010

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Publisher
American Medical Association
Copyright
Copyright © 2010 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinternmed.2009.478
Publisher site
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Abstract

Despite good intentions, patients do not always follow “doctor's orders.” It turns out that physicians are not much better, at least when it comes to adherence to clinical practice guidelines. Williams and coauthors present another compelling example. They analyzed 3533 patient visits to Australian general practitioners during the 3 years before and the 3 years after the publication of a clinical practice guideline for the treatment of low back pain.1 The introduction of a local, evidence-based clinical practice guideline had no effect on physician treatment of low back pain as measured by the frequency of patient counseling, prescription of analgesics, and use of imaging. These results are not an isolated finding. Less-than-optimal rates of physician adherence to back pain guidelines have been noted in the United States, Sweden, and Ireland.2-4 A systematic review of physician guideline adherence published a decade ago found that no specialty, practice location, or guideline topic is exempt from this observation.5 Given that clinical practice guidelines can lead to higher-quality care at a more predictable cost, how can we promote their use? Perhaps we should start by asking whose responsibility is it to ensure physician adherence to these guidelines. The definition of professionalism implies that individual physicians will strive to stay up to date and apply the most current guidelines for providing quality care.6 In addition, self-evaluation of practice performance is now a routine component for maintenance of board certification for physicians in many specialties. However, it is not enough to rely on the best efforts of physicians. There are many well-recognized barriers that prevent adherence, such as competing practice demands and the limited time to apply an increasing number of guideline recommendations.5 Professional organizations and guideline developers need to translate their work into practice. Guideline production is very resource intensive. Organizations and societies that develop clinical practice guidelines are recognizing the need to develop accompanying implementation strategies to increase the likelihood of adoption by end users.7,8 For example, the Bureau of Maternal and Child Health, in collaboration with the American Academy of Pediatrics, recently developed a comprehensive set of pediatric health supervision guidelines.9 In addition to guideline development, an implementation plan was developed to encourage physician adherence by identifying successful practice implementation examples, disseminating those models to stakeholders, and providing technical assistance for implementation. Payment structure can play a role as well. Clinical practice guidelines may be more likely to be adopted if guideline recommendations are consistent with reimbursement arrangements. As a result, the development of evidence-based reimbursement policies by third-party payers may be just as important as the development of evidence-based guidelines. “Pay for performance” initiatives, in which an external payer rewards physicians for quality achievements such as guideline adherence, seem like a natural bridge; however, data on their effectiveness are not yet clear.10 Finally, patients may be helpful in enhancing physician guideline adherence through public education programs or through public reporting programs. However, individual patient preferences about clinical care may not directly match quality clinical practice guideline recommendations. For example, a recent analysis of low rates of guideline adherence for colorectal cancer screening guidelines at one Veteran's Administration hospital found that 47% of cases were unscreened secondary to patient preference.11 In the end, all individual physicians who consider themselves professionals strive to carefully and appropriately apply the most current clinical practice guidelines for their patients. However, to help carry this burden, professional organizations that develop guidelines must take the next step to utilize their sway as opinion leaders to encourage adherence. Guideline developers should identify successful practice models that promote adherence to their guideline recommendations and disseminate those examples. Payers and practice managers need to carefully align incentives with guideline recommendations. Public health practitioners can help creatively harness patient and community knowledge, attitudes, and behaviors to influence and improve physician adherence. In addition, more studies are needed to determine the most effective strategies for implementing clinical practice guidelines. In the end, by leveraging these forces, we can reap the rewards of improved adherence and patient outcomes. Correspondence: Dr Cabana, Division of General Pediatrics, University of California, San Francisco, School of Medicine, 3333 California St, Ste 245, San Francisco, CA 94118 (michael.cabana@ucsf.edu). Financial Disclosure: None reported. Funding/Support: This work was funded by the National Heart, Lung, and Blood Institute (HL70771). References 1. National Health and Medical Research Council, Evidence-Based Management of Acute Musculoskeletal Pain: A Guide for Clinicians. Canberra, Australia NHMRC2004; 2. Jackson JLBrowning R Impact of national low back pain guidelines on clinical practice. South Med J 2005;98 (2) 139- 143PubMedGoogle ScholarCrossref 3. Overmeer TLinton SJHolmquist LEriksson MEngfeldt P Do evidence-based guidelines have an impact in primary care? a cross-sectional study of Swedish physicians and physiotherapists. Spine (Phila Pa 1976) 2005;30 (1) 146- 151PubMedGoogle Scholar 4. Fullen BMMaher TBury GTynan ADaly LEHurley DA Adherence of Irish general practitioners to European guidelines for acute low back pain. Eur J Pain 2007;11 (6) 614- 623PubMedGoogle ScholarCrossref 5. Cabana MDRand CSPowe NR et al. Why don't physicians follow clinical practice guidelines? a framework for improvement. JAMA 1999;282 (15) 1458- 1465PubMedGoogle ScholarCrossref 6. ABIM Foundation; ACP-ASIM Foundation; American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine, Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136 (3) 243- 246PubMedGoogle ScholarCrossref 7. Somerfield MREinhaus KHagerty KLBrouwers MCSeidenfeld JLyman GHAmerican Society of Clinical Oncology, American Society of Clinical Oncology Clinical Practice Guidelines: opportunities and challenges. J Clin Oncol 2008;26 (24) 4022- 4026PubMedGoogle ScholarCrossref 8. Heffner JEAlberts WMIrwin RWunderink R Translating guidelines into clinical practice: recommendations to the American College of Chest Physicians. Chest 2000;118 (2) s70- s73PubMedGoogle ScholarCrossref 9. Hagan JFShaw JSDuncan P Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. Elk Grove Village, IL American Academy of Pediatrics2008; 10. Glickman SWOu FSDelong ER et al. Pay for performance, quality of care, and outcomes in acute myocardial infarction. JAMA 2007;297 (21) 2373- 2380PubMedGoogle ScholarCrossref 11. Walter LCDavidowitz NPHeineken PACovinsky KE Pitfalls of Converting practice guidelines into quality measures: lessons learned from a VA performance measure. JAMA 2004;291 (20) 2466- 2470PubMedGoogle ScholarCrossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Feb 8, 2010

Keywords: low back pain

References