Why Don't Physicians Follow Clinical Practice Guidelines?

Cabana, Michael D.; Rańd, Cynthia S.; Powe, Neil R.; Wu, Albert W.; Wilson, Modena H.; Abboud, Paul André C.; Rubin, Haya R.

doi:10.1001/jama.282.15.1458

Cited by 5,620 publications

(2,214 citation statements)

References 75 publications

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“…There are always circumstances in which non-HDF requests are appropriate, such as severity of illness, drug intolerance, proven ine ectiveness, or safety concerns related to adverse e ects and co-morbidity. Often, these considerations will justify prescribing of (newly marketed) drugs not included in the HDF [32,45,62,63,64,65].…”

Section: Discussionmentioning

confidence: 99%

Assessment of indicators for hospital drug formulary non-adherence

Fijn

Lenderink

Egberts

et al. 2001

Eur J Clin Pharmacol

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Background: Translation of rational drug therapy into practice remains an international problem. Although pharmacotherapeutic treatment guidelines (PTGs) as managerial tools are favoured over hospital drug formularies (HDFs), the latter are still applied in most hospitals. HDF enforcement often leads to timeconsuming consultation from the perspective of both pharmacy sta and prescriber. So far, research on HDFs has only been conducted outside Europe. Moreover, this research has only been descriptive. Straightforward indicators qualitatively characterising HDF non-adherence have never been assessed. Methods: A retrospective 1:1 case-control study was conducted across three general teaching hospitals. Non-HDF requests were compared with HDF requests. Data were multivariably analysed, considering patient, prescriber, drug, and HDF characteristics as possible indicators for non-adherence. Results: HDF adherence was almost universal across characteristics. Non-adherence was characterised by newly marketed drugs, drugs that were part of patients' pre-admission drug therapy, drugs with many fellow drugs within the drug group on the market, and drugs originating from a drug group for which the HDF was highly restrictive. Contrary to common perception, nonadherence was independent of medical specialty, therapeutic area, and patient characteristics. Conclusion: This research provides an epidemiological framework for hospitals (drug and therapeutics committees) for evaluating pharmacy data on HDF nonadherence. It can be used for educational tailor-made feedback to prescribers and for drug selection when the inclusion of newly marketed drugs is considered or HDF restrictiveness for certain drug groups is reconsidered. Moreover, it demonstrates the importance of a regional approach involving secondary and primary health care to establish continuity in seamless care of drug therapy.

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Section: Discussionmentioning

confidence: 99%

Assessment of indicators for hospital drug formulary non-adherence

Fijn

Lenderink

Egberts

et al. 2001

Eur J Clin Pharmacol

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“…These statements on barriers were based on the validated framework of Cabana et al. (1999) regarding behaviour change in health care, and included the following domains: (i) knowledge (awareness or familiarity); (ii) attitude (motivation); and (iii) behaviour (external factors, time and organizational issues). The facilitators were based on a literature review by Davies, Powell and Rushmer (2007) regarding health care professionals’ views on enablers for quality improvements.…”

Section: The Studymentioning

confidence: 99%

“…The framework of Cabana et al. (1999) proposes that a wide spectrum of barriers, including barriers related to knowledge, attitude and behaviour should be assessed in order to realize the widespread behaviorial change in health care. This study was designed to assess barriers in nurses’ knowledge, attitude and behaviour to a range of NSOs, in order to give a general overview of the perceived barriers to the monitoring of NSOs.…”

Section: Introductionmentioning

confidence: 99%

Barriers and carriers: a multicenter survey of nurses’ barriers and facilitators to monitoring of nurse-sensitive outcomes in intensive care units

et al. 2017

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AimTo identify nurses’ barriers and facilitators to monitoring of nurse‐sensitive outcomes in intensive care units (ICUs), and to explore influential nurse characteristics and work environment factors.DesignA cross‐sectional survey in three Dutch ICUs between October 2013 ‐ June 2014.MethodsA questionnaire with questions regarding facilitators and three types of barriers: knowledge, attitude and behaviour. The Dutch Essentials of Magnetism II was used to examine work environments.ResultsAll 126 responding nurses identified pressure ulcers and patient satisfaction as outcomes that are nurse‐sensitive and nurses’ full responsibility. Lack of time (behaviour) was perceived as the most prominent barrier, followed by unfamiliarity with mandatory indicators (knowledge), and unreliability of indicators as benchmark data (attitude). Education and clear policies were relevant facilitators. Of nurse characteristics, only regularity of shifts was related to perceived attitude related barriers. The work environment factor “clinical autonomy” was potentially associated with behaviour related barriers.

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“…Understanding how to increase the perceived "cost" of overprescribing such that risks are stark 3 and framing guidelines as worthwhile investments of time is critical. If CPOE modifications are not matched with parallel alterations in underlying clinician knowledge, attitudes, and behaviors, the effects may be temporary and may fall short of the goal of significant and long-lasting reductions in inappropriate antibiotic utilization.…”

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confidence: 99%

Capsule Commentary on Tannenbaum et al., Nudging Physician Prescription Decisions by Partitioning the Order Set: Results of a Vignette-Based Study

2014

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T annenbaum et al. 1 use vignettes to explore the effect of the order that information is provided in computerized provider order entry (CPOE) on policy-critical practices, such as use of antibiotics. With the proliferation of CPOE systems, a number of advantages associated with their use have been revealed: reducing errors caused by misreading handwriting, reducing duplicate or incorrect doses or tests, and alerting providers to potential medication interactions. In this value-focused environment, administrators have become much more highly capable and willing to make design and implementation decisions that may affect clinical practice.This process change is attractive in its relative ease of implementation and dissemination, given the difficulty in changing antibiotic prescribing behavior. However, success will depend on effective integration into existing workflow. Clinicians are known to alter quality and safety measures in order to expedite treatment or address patient concerns. These "workarounds" have been studied in the context of healthcare administration safeguards, 2 and their effect on the subversion of medication safety measures illustrates likely challenges to EMR design changes motivated by this work.The problems of workarounds as well as shortcuts reflect underlying forces behind the change in the behavior studied. CPOE users employ a variety of "shortcuts" to increase efficiency and reduce search costs. The authors suggest that new ordering could be a shortcut for signaling which choices are "common or appropriate". 1 Future research on inappropriate use should grapple directly with when and why providers employ shortcuts. The shortcut may dictate that it is "safer" to prescribe, given uncertainty, that it is easier to quiet a demanding patient with a prescription, or that it is faster to write a script and move to the next appointment.Understanding how to increase the perceived "cost" of overprescribing such that risks are stark 3 and framing guidelines as worthwhile investments of time is critical. If CPOE modifications are not matched with parallel alterations in underlying clinician knowledge, attitudes, and behaviors, the effects may be temporary and may fall short of the goal of significant and long-lasting reductions in inappropriate antibiotic utilization. The inclusion of user input in CPOE design and the study of the impact on work practices of prescribing providers warrants more effort and attention.

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Why Don't Physicians Follow Clinical Practice Guidelines?

Cited by 5,620 publications

References 75 publications

Assessment of indicators for hospital drug formulary non-adherence

Assessment of indicators for hospital drug formulary non-adherence

Barriers and carriers: a multicenter survey of nurses’ barriers and facilitators to monitoring of nurse-sensitive outcomes in intensive care units

Capsule Commentary on Tannenbaum et al., Nudging Physician Prescription Decisions by Partitioning the Order Set: Results of a Vignette-Based Study

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