Putting Guidelines into Practice


The NICS Gaps report

How can we bridge the ‘chasm’ between what the evidence tells us we should achieve in chronic disease, and what we manage to achieve in practice? (Cf NICS Gap Report)

This is perhaps the key question that we are collaborating to answer.

Ralph Audehm has directed us to a few recent articles that aim to identify the barriers to better care.

The BMC Family Practice reports on the results of sending case vignettes to 12,000 primary care physicians – of which 888 responded. (I am sure I would have been in the 11,112 majority that did not).

“Knowledge and attitudes of primary care physicians in the management of patients at risk for cardiovascular events”

An analysis of the responses to the case vignetter identified a low rate of adherence to guidelines (and I fall into the category least likely to provide best care – in practice more than 10 years and having a high proportion of patients with chronic disease!)

The following were some of the barriers to guideline adherence –

  • Cost of medications (88%)
  • Number of Medications for adequate blood pressure control (75%)
  • Patient Adherence (74%)
  • Inadequate time for counselling
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  • Inadequate patient education tools
  • Inadequate knowledge and skills to recommend dietary changes

The study concludes that

Innovative educational approaches are needed to address barriers, and target specific groups of physicians to facilitate the implementation of guideline-based recommendations in CVD management.

Do you agree with that conclusion?

Is this really a deficiency of education? Would more educational opportunities for the physicians lead to different outcomes? Would this address the barriers that this very study identified?

Every system produces exactly the result it is designed to produce.
We know that ‘Doing more of the same’ is an ineffective way of producing better outcomes.

What would you recommend to produce better guideline adherence?

You can compare the results of the ‘Translate‘ study which changed the systems in use in a practice.

Ralph forwarded another study on ‘Physician Inertia’.

“Factors Associated With Intensification of Oral Diabetes Medications in Primary Care Provider-Patient Dyads: A Cohort Study” get Diflucan

121 patients with diabetes were followed over a 2 year period, during which time there were 575 consultations in which patients had a most recent HbA1C >=8. However, treatment was intensified on only 22% of these consultations.

Treatment was more likely to be increased the higher the HbA1C (as you would expect). Other positive factors included

  • patients with visits that were “routine”
  • patients taking two or more oral diabetes drugs
  • patients with longer intervals between visits

In contrast, patients that were less likely to have treatment increased were those

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  • patients with less recent A1C measurements
  • patients with a higher number of prior visits (OR per prior visit
  • patients who were African American.

Your comments on these studies or other issues welcome below.
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