Patient and physician related factors of adherence to evidence based guidelines in diabetes mellitus type 2, cardiovascular disease and prevention: a cross sectional study

Abstract

BackgroundPatients do not always receive guideline-adherent therapy, yet little is known about the underlying causes on the patients’ side. We quantified non-guideline-adherent treatment of chronic diseases (diabetes mellitus, hypertension, cardiovascular disease, heart failure, atrial fibrillation) in primary care and analysed the causes from the physician’s as well as the patient’s view.MethodsWith the intention to analyze the frequency and causes of non-guideline-adherent treatment of patients with chronic diseases, we drew a random sample of 124 general practitioners (GP) in Salzburg, Austria, of which 58 (46.8%) participated. In the participating GP surgeries, we consecutively recruited 501 patients with at least one of the target-diseases and checked the guideline conformity of treatment using 9 quality indicators. We then interviewed the patients as well as the general practitioners regarding factors affecting deviation from guideline recommendations.ResultsOf the 501 patients, a total of 1224 quality indicators could be analysed. Non-adherence to guideline recommendations were present in 16.8% (n = 205, 95% CI 14.7 to 18.8%) of all quality indicators. In 61.5% of these cases (n = 126, 95% CI 53.0 to 70.0%) the treatment was wrongly judged as not recommended by the physicians. In 10.2% (n = 21, 95% CI 0 to 23.2%) physicians attributed non-adherence to patient’s non-compliance, and in 10.7% (n = 22, 95% CI 0 to 23.7%) to an adverse drug event, whereas only 5.4% (n = 11, 95% CI 0 to 18.7%) of non-adherence was related to an adverse drug event reported by the patients. Patients were unaware regarding the reason for non-adherent therapy in 64.4% (n = 132, 95% CI 56.2 to 72.6%) of the quality indicators. In 20.0% (n = 41, 95% CI 7.8 to 32.2%) patients regarded a drug as not needed.ConclusionsGuideline adherence in chronic care was relatively good in our study sample, but still leaving room for improvement. Physicians’ lack of knowledge and patients’ lack of awareness account for about 70% of non-adherence, indicating the necessity to improve physician education, and patient involvement. In about 30% of the quality indicators not fulfilled, non-adherence is due to other reasons like adverse drug events or patients not willing to take a recommended drug.

Why are clinical practice guidelines not followed?

“…Lugtenberg et al studied the causes in three guidelineson red eyes, stroke and thyroid disease. They found that there were different reasons for non-compliance associated with each CPG and, moreover, that clinicians and patients have different views of their non-applicability [14,24]. Berner and Graber comprehensively reviewed the effect of physician over confidence in their own ability as a cause of diagnostic errors.…”

Adesão ao tratamento na hipertensão e diabetes mellitus: revisão integrativa

“…35 No presente estudo ainda verificamos que a hipertensão e diabetes estão associadas. Do total de estudos incluídos, em 23% os pacientes possuem ambas as doenças 14,17,19,23,28,34 o que incrementa a complexidade das medidas e, principalmente, do manejo farmacológico, tendo em vista que aumenta a quantidade de fármacos prescritos assim como a necessidade de intensificação das medidas não-farmacológicas.…”

“Weariness” and “unpleasantness” reduce adherence to branched‐chain amino acid granules among Japanese patients with liver cirrhosis: results of a single‐center cross‐sectional survey

“…Fürthauer et al . found that patients with diabetes with low adherence may not take their medication as prescribed because they accept their symptoms as normal, or may not even notice them . In a review, Lerman cited other possible reasons for low adherence among diabetic patients including lack of social support, poor knowledge about the implications of disease and of not taking medication, substance abuse, and even forgetfulness .…”