PHILADELPHIA -- A study of internists in office practice reveals some may disregard medical guidelines because they find guidelines do not apply to all of their patients. Researchers say oversight and patient non-adherence still affected physicians’ ability to comply with guidelines, but physician disagreement with so-called “best practices” was a previously unstudied factor.
The study, “Physician Explanations for Failing to Comply with ‘Best Practices,’” was conducted by the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) and appears in the September/October 2001 issue of Effective Clinical Practice, published by ACP-ASIM in collaboration with the Alliance of Community Health Plans (ACHP).
Eighty-five internists volunteered to review their charts of patients with type II diabetes and track how they had met five diabetes care measures. When a practice was not followed, physicians gave their reasons in open-ended comments. In 1,755 patient encounters overall, physicians did not follow 24 percent of the care measures. ACP-ASIM researchers analyzed their comments for evidence of disagreement with medical guidelines.
Noncompliance rates for the diabetes practices ranged from 15 percent for annual lipid profile to 46 percent for screening microalbuminuria. The physicians’ comments suggested that oversight, patient non-adherence (missed appointments, for example) and systems issues (lapses in communication, inadequate insurance) were common reasons for noncompliance.
However, noncompliance also resulted from a conscious decision made by the physician. A common rationale was that the patient had more pressing medical problems, or that the best practice did not apply to the patient either because of advanced age or established diagnosis.
“We know doctors do not always follow practice guidelines, which is not necessarily a bad thing because not all patients are the same. Our study suggests that noncompliance may reflect valid questions about the usefulness and applicability of a best practice to an individual patient,” said lead author Christel Mottur-Pilson, PhD, Director of the ACP-ASIM Scientific Policy Division. Her co-authors were colleagues Vincenza Snow, MD, and Kyle Bartlett, PhD.
The internists who volunteered for the study are members of ACP-ASIM who had joined a practice-based research network called “QNet,” short for Quality Network. An ACP-ASIM program, QNet aims to raise physician awareness of best practices and to provide a glimpse into the constraints and reality of everyday office-based care.
The American College of Physicians-American Society of Internal Medicine is the nation’s largest medical specialty society. Its membership comprises more than 115,000 internal medicine physicians and medical students.
The Alliance of Community Health Plans is dedicated to helping participating plans improve the health of their members and their communities. ACHP includes 12 leading non-investor owned and provider-based health plans serving more than 12 million Americans.