106. The Usefulness of Clinical Practice Guidelines: Views from the Foot Soldiers
JK Zemencuk, Ann Arbor VA Center for Practice Management and Outcomes Research; RA Hayward, Ann Arbor VA Center for Practice Management and Outcomes Research; L Wyszewianski, The University of Michigan School of Public Health; LA Green, The University of Michigan School of Medicine and Department of Family Medicine
Objectives: The VHA has mandated the implementation of clinical practice guidelines (CPGs) as a "strategy to optimize access, use best practices, and improve patient participation in decision making" (VHA Directive 96-053). While patient factors and treatment resources require consideration, the ultimate success of CPGs depends upon their integration into practice by individual clinicians. We examined VA physicians' attitudes toward aspects of clinical practice affecting acceptance of and compliance with CPGs.
Methods: A questionnaire assessing attitudes toward factors influencing clinical care and CPG use was sent to a nationwide sample of 1,160 VA primary care physicians. The questionnaire included a 14-item instrument developed by LW and LG to assess information style. 800 (69%) physicians completed questionnaires. Analyses included frequency distributions and factor analyses to analyze dimensionality of response style to new information. Three dimensions emerged: evidence/clinical experience (Cronbach's alpha=.72); practicality (alpha=.65); and time (alpha=.63). Composite scores of each dimension were included in a multivariable logistic regression model to examine their effect on perception of CPG usefulness, controlling for years in practice.
Results: Most VA physicians (89%) agree that evidence-based medicine makes "a lot of sense." However, only about two-thirds (65%) view CPGs as useful in daily patient care. Attitude toward and reported adherence to CPGs appear to depend, in part, upon the practicality of use and availability of time. For example, 69% report following CPGs "if they are not too much hassle," while 46% do "as long as they don't interfere too much with patient flow." Only slightly more than half (55%) disagree that they are "too busy taking care of patients to keep up with recent literature." In multivariable analysis, those reporting not having time to review the medical literature are less likely to view CPGs as useful (OR 0.41; 95% CI=0.29, 0.56). Viewing CPGs as useful also depends upon one's perception of the importance of randomized controlled trial (RCT) results in patient care, relative to clinical experience and/or opinions of respected authorities. While nearly three-quarters (72%) agree that the "best guidelines are based on the results of RCTs" fewer (57%) feel care should be based on RCTs "rather than [on] the opinion of respected authorities." However, less than one-third (32%) agrees "clinical experience is more important than RCTs." Physicians who perceive RCT results and evidence-based medicine to be less important than clinical experience are less likely to find CPGs useful (OR 0.70; 95% CI=0.60, 0.82).
Conclusions: Less than two-thirds of VA physicians viewed CPGs as very useful in caring for their patients. Physicians who reported a lack of time or placed a greater value on clinical experience relative to evidence-based medicine were less likely to view CPGs as useful.
Impact: These findings have significant implications for improving guideline adherence at the VHA. While there are likely a variety of barriers affecting adherence, integration of CPGs into practice as a means of improving patient outcomes will, in part, depend upon interventions that take into account physicians' available time and address their assessment of evidence-based medicine relative to clinical experience in the delivery of patient care.