Use and Perceptions of Clinical Practice Guidelines by Internal Medicine Physicians

Center for Clinical and Genetic Economics, Duke Clinical Research Institute, NC 27715, USA.
American Journal of Medical Quality (Impact Factor: 1.25). 05/2007; 22(3):170-6. DOI: 10.1177/1062860607300291
Source: PubMed


The authors sought to explore the use and perceptions of clinical practice guidelines among internal medicine physicians. Through a Web-based survey, 201 board-certified internal medicine physicians rated their opinions on several statements using 7-point Likert scales. Most respondents (74.7%) felt that guidelines were suitable for at least half of their patients, although a failure to take comorbid conditions into account was a frequently cited barrier. For patients with cardiovascular disease, there was no difference between individual internists' perceptions of their own compliance with guidelines and their estimates of cardiologists' compliance (P = .14). A large majority of respondents (70.7%) believed that guideline committee member participation in industry-funded research introduces bias into guideline content (median [interquartile range], 5 [4-6]). Although most respondents felt that measuring physicians against guideline-based performance measures encourages evidence-based medicine (76.5%), opinions were split as to whether this practice distracts from patient care or compromises physician autonomy.

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    • "Although numerous guidelines exist for prevention of CVD, risk factor control remains sub-optimal in high-risk patients and in those with established CVD [1]. Physician adherence to guidelines for prevention of CVD in general has been less than optimal [2], [3]. Moreover, published literature has demonstrated a ‘discrepancy between intentions and practise’ in the treatment of hypertension and have highlighted the physicians’ difficulty in following the complex clinical guidelines [4]. "
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    ABSTRACT: The potential role of DSS in CVD prevention remains unclear as only a few studies report on patient outcomes for cardiovascular disease. A systematic review and meta-analysis of randomised controlled trials and observational studies was done using Medline, Embase, Cochrane Library, PubMed, Amed, CINAHL, Web of Science, Scopus databases; reference lists of relevant studies to 30 July 2011; and email contact with experts. The primary outcome was prevention of cardiovascular disorders (myocardial infarction, stroke, coronary heart disease, peripheral vascular disorders and heart failure) and management of hypertension owing to decision support systems, clinical decision supports systems, computerized decision support systems, clinical decision making tools and medical decision making (interventions). From 4116 references ten studies met our inclusion criteria (including 16,312 participants). Five papers reported outcomes on blood pressure management, one paper on heart failure, two papers each on stroke, and coronary heart disease. The pooled estimate for CDSS versus control group differences in SBP (mm of Hg) was - 0.99 (95% CI -3.02 to 1.04 mm of Hg; I(2) = 0; p = 0.851). DSS show an insignificant benefit in the management and control of hypertension (insignificant reduction of SBP). The paucity of well-designed studies on patient related outcomes is a major hindrance that restricts interpretation for evaluating the role of DSS in secondary prevention. Future studies on DSS should (1) evaluate both physician performance and patient outcome measures (2) integrate into the routine clinical workflow with a provision for decision support at the point of care.
    PLoS ONE 10/2012; 7(10):e47064. DOI:10.1371/journal.pone.0047064 · 3.23 Impact Factor
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    • "In fact, physicians see guidelines and other initiatives based on experimental medicine as appropriate and clearly consistent with the intended nature of practice (Malacco et al., 2005; Shea, DePuy, Allen, &Weinfurt, 2007). In one survey, only 3% of family practice physicians disagreed in principle with evidence-or guideline-based practice and indicated resistance to such practice (Wolfe, Sharp, & Wang, 2004). "
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    ABSTRACT: The escalating costs of health care and other recent trends have made health care decisions of great societal import, with decision-making responsibility often being transferred from practitioners to health economists, health plans, and insurers. Health care decision making increasingly is guided by evidence that a treatment is efficacious, effective-disseminable, cost-effective, and scientifically plausible. Under these conditions of heightened cost concerns and institutional-economic decision making, psychologists are losing the opportunity to play a leadership role in mental and behavioral health care: Other types of practitioners are providing an increasing proportion of delivered treatment, and the use of psychiatric medication has increased dramatically relative to the provision of psychological interventions.Research has shown that numerous psychological interventions are efficacious, effective, and cost-effective. However, these interventions are used infrequently with patients who would benefit from them, in part because clinical psychologists have not made a convincing case for the use of these interventions (e.g., by supplying the data that decision makers need to support implementation of such interventions) and because clinical psychologists do not themselves use these interventions even when given the opportunity to do so.Clinical psychologists' failure to achieve a more significant impact on clinical and public health may be traced to their deep ambivalence about the role of science and their lack of adequate science training, which leads them to value personal clinical experience over research evidence, use assessment practices that have dubious psychometric support, and not use the interventions for which there is the strongest evidence of efficacy. Clinical psychology resembles medicine at a point in its history when practitioners were operating in a largely prescientific manner. Prior to the scientific reform of medicine in the early 1900s, physicians typically shared the attitudes of many of today's clinical psychologists, such as valuing personal experience over scientific research. Medicine was reformed, in large part, by a principled effort by the American Medical Association to increase the science base of medical school education. Substantial evidence shows that many clinical psychology doctoral training programs, especially PsyD and for-profit programs, do not uphold high standards for graduate admission, have high student-faculty ratios, deemphasize science in their training, and produce students who fail to apply or generate scientific knowledge.A promising strategy for improving the quality and clinical and public health impact of clinical psychology is through a new accreditation system that demands highquality science training as a central feature of doctoral training in clinical psychology. Just as strengthening training standards in medicine markedly enhanced the quality of health care, improved training standards in clinical psychology will enhance health and mental health care. Such a system will (a) allow the public and employers to identify scientifically trained psychologists; (b) stigmatize ascientific training programs and practitioners; (c) produce aspirational effects, thereby enhancing training quality generally; and (d) help accredited programs improve their training in the application and generation of science. These effects should enhance the generation, application, and dissemination of experimentally supported interventions, thereby improving clinical and public health. Experimentally based treatments not only are highly effective but also are cost-effective relative to other interventions; therefore, they could help control spiraling health care costs. The new Psychological Clinical Science Accreditation System (PCSAS) is intended to accredit clinical psychology training programs that offer highquality science-centered education and training, producing graduates who are successful in generating and applying scientific knowledge. Psychologists, universities, and other stakeholders should vigorously support this new accreditation system as the surest route to a scientifically principled clinical psychology that can powerfully benefit clinical and public health.
    Psychological Science in the Public Interest 01/2009; 9(2):67-103. DOI:10.1111/j.1539-6053.2009.01036.x
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    • "In fact, physicians see guidelines and other initiatives based on experimental medicine as appropriate and clearly consistent with the intended nature of practice (Malacco et al., 2005; Shea, DePuy, Allen, & Weinfurt, 2007). In one survey, only 3% of family practice physicians disagreed in principle with evidence-or guideline-based practice and indicated resistance to such practice (Wolfe, Sharp, & Wang, 2004). "
    Psychological Science in the Public Interest 11/2008; 9(2). DOI:10.1111/j.1539-6053.2009.01035.x
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