Physicians' Attitudes Toward Guidelines for Stroke: A Survey of Korean Neurologists

Abstract

Background and Purpose
Clinical practice guidelines (CPGs) are regarded as an essential guidance tool for practicing physicians. We surveyed physicians in Korea in order to evaluate their attitudes toward the Korean CPGs for stroke.

Methods
We obtained participation agreement for our survey from 27 centers of the 33 most actively contributing to the Korean Stroke Registry. A total of 174 neurologists participated in a questionnaire interview regarding their attitudes toward CPGs for stroke.

Results
Of 174 participating neurologists, 65 (37.4%) were stroke neurologists. The average age was 33.6±7.1 and 49 (28.2%) were female. Most of the respondents held positive attitudes and opinions regarding the use of the guidelines, whereas only a small percentage (14.9%) responded negatively. More than 60% of the physicians in the survey reported adherence to the Korean CPGs in dyslipidemia management for the secondary prevention of stroke.

Conclusions
The positive attitudes and opinions toward the guidelines imply that physicians' attitudes should not be regarded as a potential barrier to the implementation of Korean CPGs for stroke practiced by general physicians.

Full text

Copyright © 2014 Korean Stroke Society
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pISSN: 2287-6391 • eISSN: 2287-6405 http://j-stroke.org 81
Physicians’ Attitudes Toward Guidelines for Stroke:
A Survey of Korean Neurologists
Hyung-Min Kwon,a Mi Sun Oh,b Hye-Yeon Choi,c A-Hyun Cho,d Keun-Sik Hong,e Kyung-Ho Yu,b
Hee-Joon Bae,f Juneyoung Lee,g Byung-Chul Leeb
aDepartment of Neurology, Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
bDepartment of Neurology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
cDepartment of Neurology, Gangdong Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
dDepartment of Neurology, Yeouido St. Mary’s Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea
eDepartment of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea
fDepartment of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
gDepartment of Biostatistics, Korea University College of Medicine, Seoul, Korea
Correspondence: Byung-Chul Lee
Department of Neurology, Hallym
University Sacred Heart Hospital,
Hallym University College of Medicine,
22 Gwanpyeong-ro 170beon-gil,
Dongan-gu, Anyang 431-070, Korea
Tel: +82-31-380-3741
Fax: +82-31-381-4659
E-mail: ssbrain@hallym.ac.kr
Received: January 13, 2014
Revised: March 26, 2014
Accepted: April 8, 2014
This study was sponsored by Pfizer
Pharmaceuticals Korea Ltd.
The authors have no financial conflicts of
interest.
Background and Purpose Clinical practice guidelines (CPGs) are regarded as an essential
guidance tool for practicing physicians. We surveyed physicians in Korea in order to evalu-
ate their attitudes toward the Korean CPGs for stroke.
Methods We obtained participation agreement for our survey from 27 centers of the 33
most actively contributing to the Korean Stroke Registry. A total of 174 neurologists partici-
pated in a questionnaire interview regarding their attitudes toward CPGs for stroke.
Results Of 174 participating neurologists, 65 (37.4%) were stroke neurologists. The average
age was 33.6 ±7.1 and 49 (28.2%) were female. Most of the respondents held positive atti-
tudes and opinions regarding the use of the guidelines, whereas only a small percentage
(14.9%) responded negatively. More than 60% of the physicians in the survey reported ad-
herence to the Korean CPGs in dyslipidemia management for the secondary prevention of
stroke.
Conclusions The positive attitudes and opinions toward the guidelines imply that physi-
cians’ attitudes should not be regarded as a potential barrier to the implementation of Ko-
rean CPGs for stroke practiced by general physicians.
Keywords Guideline; Stroke; Attitude
Original Article
Journal of Stroke 2014;16(2):81-85
http://dx.doi.org/10.5853/jos.2014.16.2.81
Introduction
Clinical practice guidelines (CPGs) are systematically devel-
oped statements aimed at helping practitioners and patients
make informed health care decisions in specific clinical circum-
stances.1 Investigators of the Clinical Research Center for Stroke
(CRCS), funded by the Ministry of Health and Welfare of Ko-
rea, developed and published the first edition of the Korean
CPGs for stroke in 2009, and have since updated the guidelines
to reflect and incorporate new evidence pertinent to clinical
practice. The Korean CPGs for stroke have been endorsed by
relevant and respected academic societies and have been dis-
tributed in the forms of monographs, summary manuals, freely
accessible PDF files on the websites of the CRCS and the Kore-
an Stroke Society, and through smart phone applications in or-
der to ensure widespread dissemination and implementation.
CPGs, which help incorporate scientific advancements into
daily practice, are expected to improve the quality of care, lead

Kwon, et al. Attitudes Toward Korean CPGs for Stroke
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to better patient outcomes, avoid unnecessary cost, and serve as
good educational tools.2 However, physicians’ attitudes toward
CPGs, as well as their confidence in the instruments, are essen-
tial for successful implementation and physician adherence.3
Since the publication of the Korean CPGs for stroke, the atti-
tudes and confidence levels of Korean neurologists toward the
guidelines have not been explored.
Methods
This study was designed a priori as a sub-study within the Real
world of Lipid-Lowering therapy in Korean Stroke patients
(ROLLERKOST), which aimed to assess Korean neurologists’
knowledge of current dyslipidemia management guidelines and
guideline-based discharge prescriptions for statin amongst pa-
tients hospitalized with acute ischemic stroke or transient isch-
emic attack. Details of the ROLLERKOST study have already
been published,4 but to summarize, 33 centers that actively enroll
their patients in the Korean Stroke Registry were selected from a
total of 86 neurology training hospitals in Korea.5 These 33 cen-
ters were sent an e-mail describing the purpose of the study and
requesting their participation. Consent was received from 27
centers. Between November 2010 and December 2011, we con-
ducted a survey that directly interviewed neurologists (board-
certified neurologists and residents) from the 27 centers, using a
structured questionnaire composed of four main principles:
physician characteristics (5 items), practice patterns of dyslipid-
emia management (15 items), knowledge of the current dyslip-
idemia management guidelines (10 items) and attitudes to and
confidence in the current guidelines (21 items).
The current study analyzed responses to the 21 questions on
physicians’ attitudes towards and confidence in the current Ko-
rean CPGs for stroke (Table 1). We used a 5-point Likert scale
to rate physicians’ responses to each of the 21 questions: strongly
agree, agree, neither agree nor disagree, disagree, and strongly
disagree. The respondents’ attitudes were then divided into posi-
tive views (strongly agree and agree) and negative views (strong-
ly disagree and disagree). Neutral responses (neither agree nor
disagree) were disregarded. The internal consistency of the re-
sponses of physicians to the 21 questions was examined using
Cronbach’s alpha. In measuring the consistency, the responses of
items 14, 15, 16, 17, 18, 20, and 21 as listed in Table 1 were re-
versed to ensure that all items had the same direction. Descrip-
tive statistics were used to present the results of physicians’ re-
sponses to each item. In addition, we investigated which guide-
lines Korean neurologists usually referred to during their clinical
practice of dyslipidemia management (the Korean CPGs, Na-
tional Cholesterol Education Program-Adult Treatment Panel
III guidelines,6 or the reimbursement guidelines provided by the
Korean Health Insurance Review and Assessment Service).
Results
Of the 33 centers contacted, 27 centers participated in the
study (81.8%). These consisted of 18 university hospitals, 7 af-
filiated hospitals, and 2 secondary referral hospitals. A total of
174 neurologists who were both actively involved in managing
patients and consented to face-to-face interviews responded to
the questionnaire. The average age of respondents was 33.6
years± 7.1, 49 (28.2%) were female, 73 (42.0%) were board-
certified neurologists and 66 (37.9%) indicated that their sub-
specialty was stroke medicine. Detailed demographic character-
istics are presented in Table 2. The internal consistency of re-
sponses was relatively high (Cronbach’s α = 0.8677).
Most of the respondents reported a positive attitude to the
use of CPGs for stroke in their clinical decision-making (Figure
1). The mean value of negative views regarding all question-
naires (excluding the statements that were neither positive nor
negative) was 14.9%. More than 70% of the respondents re-
sponded that they used the Korean CPGs for stroke and be-
lieved that treatments following these guidelines are likely to be
effective without infringing on physician autonomy. Only 34%
of the respondents, however, were confident that CPGs for
stroke are unbiased statements, and a sizable proportion of re-
Table 1. Items included in the questionnaire
Item
1. Too simplified for use in clinical practice
2. Too strict for use in clinical practice
3. Infringement of physician’s autonomy
4. Increased probability of medico-legal suit
5. Developed by less experienced physicians
6. Pressure on physician’s decision-making in clinical practice
7. Too inaccessible for use in clinical practice
8. Disagreement with guidelines
9. Treatments following guidelines are likely to be ineffective
10. Difficulty in changing his/her current practice pattern
11. Lack of time to strictly follow guidelines
12. Lack of educational materials
13. Difficulty in using guidelines
14. Developed to improve quality of care
15. Developed to cut down health care costs
16. Developed by experts without any bias
17. Providing expert advice in a convenient way
18. Good educational tool
19. Too complicated for use in clinical practice
20. Have you ever read the dyslipidemia management of the current Korean
Stroke Guidelines?
21. Are you well aware of the dyslipidemia management guidelines for secondary
stroke prevention?

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spondents (48.9%) complained about a perceived lack of edu-
cation materials, despite a healthy majority of neurologists hold-
ing the belief that CPGs for stroke are developed to improve the
quality of care afforded to patients and that they are a good edu-
cational tool (Figure 1).
In terms of the level of knowledge of current dyslipidemia
management guidelines, there was no difference in the attitudes
or confidence levels on the distribution of responses between
the higher- and lower-knowledge level groups for all questions.
The median score for the neurologists’ knowledge of the current
guidelines was 70 (range, 30-100). A total of 79 (45.4%) neurol-
ogists were thus categorized into the higher-level knowledge
group, having achieved a score of > 70, and 95 (54.6%) were
categorized into the lower-level knowledge group. When be-
tween-group responses were compared for specialization (stroke
neurologists vs. non-stroke neurologists) and certification
(board-certified neurologists vs. residents), stroke neurologists
and board-certified neurologists showed significantly higher
positive responses (3.58 ±0.41 vs. 3.39 ± 0.40, P= 0.0027; 3.57±
0.42 vs. 3.38 ± 0.39, P=0.0034, respectively).
Table 2. Demographic characteristics of interviewed neurologists (n= 174)
Characteristic Number (%)
Age (yr)
20-29 70 (40.2)
30-39 65 (37.4)
40-49 35 (20.1)
50-59 4 (2.3)
Gender
Male 125 (71.8)
Female 29 (28.2)
Physicians
Residents 101 (58.1)
Board-certified neurologists 73 (41.9)
Stroke subspecialty 66 (37.9)
Years of being a neurologist
0-1 42 (24.1)
2-6 64 (36.8)
7-10 14 (8.1)
11-15 20 (11.5)
>15 34 (19.5)
Figure 1. Attitudes and opinions of Korean neurologists toward clinical practice guidelines for stroke.
80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Questionnaire’s item number
Percentage of respondents with positive and negative views
Percentage of respondents with practice in using clinical
practice guidelines for dyslipidemia management
Korean clinical practice
guidelines for stroke 63.8
32.2
4.6
American heart
association guideline
Korean insurance guideline
Figure 2. Respondents’ work habits in using clinical practice guidelines for
dyslipidemia management.
Negative views
Positive views

Kwon, et al. Attitudes Toward Korean CPGs for Stroke
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Respondents’ practical use of CPGs for stroke is presented in
Figure 2. It was found that over 60% of the health care providers
in this survey adhered to domestic CPGs during dyslipidemia
management (American Heart Association guidelines, 32%,
Korean Health Insurance guidelines, 5%).
Discussion
Before designing a strategy for the implementation of CPGs, it
is important to explore the attitudes and opinions held by health
care professionals. Skeptical opinions negatively influence the
implementation of guidance, either directly or indirectly, through
the creation of an unfavorable environment characterized by lack
of support from peers and superiors.7 The positive attitudes and
opinions toward CPGs for stroke held by Korean neurologists as
reported in this survey, combined with the findings of previous
studies among diverse groups of health care professionals,8,9 indi-
cate that the current attitudes of physicians do not form a barrier
to the future implementation of CPGs for stroke.
Responses to the questionnaire were reasonably consistent
for all respondents (Cronbach’s α= 0.8677). It was, however,
somewhat discouraging that a negative average response to the
statement “The specialists’ opinions are coordinated without
any bias” (item number 16) was obtained, as similar questions
such as “They are made by specialists who lack actual experi-
ence in medical fields” (item number 5) and “It is hard to agree
on the guidelines” (item number 8), yielded positive responses
(Figure 1). This discrepancy might be explained by the nega-
tive phraseology of the statement, but the possibility that this
might be a true response cannot be excluded.
Respondents’ work habits also concurred with their attitudes
and opinions toward CPGs for stroke. A total of 64% of respon-
dents stated that they follow the treatment advised by the dys-
lipidemia guidelines, and 66.5% had already read the dyslipid-
emia guidelines in the management of stroke patients (Figure
2). This finding might be related to professionals’ experience in
using CPGs for stroke and a culture of evidence-based practice.
Furthermore, specific criteria, such as whether the source of the
guidelines is a credible and respected body or organization, en-
courage health care providers to use and adhere to certain CPGs.10
As a result, the fact that our CPGs for stroke have been accredit-
ed by the Korean Stroke Society, the Korean Neurological As-
sociation, and the Korean Society of Cerebrovascular Surgeons
might be one of the more significant reasons for their imple-
mentation.
In our previous ROLLERKOST study, Korean neurologists
with a higher knowledge level were more likely to adhere to
guideline-based discharge prescription of statin.4 In this analysis,
however, there was no significant difference in the attitudes or
confidence on the distribution of responses between the higher-
and lower-knowledge level groups for all questions. It has not
been well demonstrated whether knowledge level is associated
with adherence to guidelines in clinical practice. Physicians’ in-
creased familiarity with the guidelines and their improved
knowledge of them may correlate with a higher rate of adher-
ence to prescription, but there was no association between
knowledge level and attitudes toward guidelines for stroke.
To the authors’ knowledge, this is the first study in which atti-
tudes towards CPGs for stroke among Korean neurologists
have been examined. However, we also admit several method-
ological limitations. Respondent physicians were affiliated with
neurology training hospitals, so this may limit the generalizabil-
ity of our findings. Moreover, the mean age of physicians was
quite low because most respondents were either trainee resi-
dents or had only become certified neurologists within the last
six years. Further studies should therefore investigate the rea-
sons behind non-adherence following the implementation of
specific CPGs among general physicians of a wider age range.
Conclusions
This study shows that most of the respondents in our survey
held positive attitudes and opinions regarding the use of the
Korean CPGs for stroke, whereas only a small percentage re-
sponded negatively. The positive attitudes and opinions toward
the guidelines suggest that physicians’ attitudes should not be
regarded as a potential barrier to the implementation of Korean
CPGs for stroke.
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