Numerous evidence-based clinical practice guidelines recommend specific approaches to clinical care, but we do not know how many doctors and other clinicians follow these guidelines. We do know that passive guideline dissemination has rarely been effective in changing clinician behavior. Methods that have been shown to be effective in specific settings include use of peer-opinion leaders, clinical practice audit and feedback, educational interventions, small group consensus processes, more intensive academic detailing, prospective reminder systems, and computer-based guideline implementation.
Three recent studies, described here and supported in part by the Agency for Healthcare Research and Quality, examined the impact of various approaches to integrate guidelines and other evidence into clinical practice.
Fine, M.J., Stone, R.A., Lave, J.R., and others (2003, October). "Implementation of an evidence-based guideline to reduce duration of intravenous antibiotic therapy and length of stay for patients hospitalized with community-acquired pneumonia: A randomized controlled trial." (AHRQ grant HS08282). American Journal of Medicine 115, pp. 343-351.
Hospitals can reduce the duration of intravenous antibiotic therapy and length of hospital stay for patients hospitalized with community acquired pneumonia without affecting patient outcomes. They can accomplish this by following a guideline that sets forth criteria for converting these patients from intravenous to oral antibiotic therapy as well as criteria that determine when the patient is sufficiently stable for hospital discharge, concludes this study. The investigators randomly enrolled 325 control and 283 intervention patients who were admitted to one of seven Pittsburgh medical centers by one of 116 physician groups.
At each site, they randomly assigned physician groups to receive a practice guideline alone (controls) or a practice guideline that was implemented using a multifaceted strategy (including real-time physician reminders and site-specific detail sheets promoting recommended actions placed in the physician progress notes section of each patient's chart, followed by a call from the research nurse about followup actions). The researchers measured the effectiveness of guideline implementation by the duration of intravenous antibiotic therapy and length of hospital stay.
The median duration of intravenous antibiotic therapy was 3 days for patients in the intervention group and 4 days for patients in the control group, with intravenous antibiotic therapy discontinued 23 percent more rapidly (borderline significance) for patients in the intervention group. Intervention patients were also discharged at a slightly (but not significantly) more rapid rate (16 percent). These effects varied by study site but not by patient risk class. Fewer intervention than control patients (55 vs. 63 percent) suffered medical complications during their hospitalization, and there were no differences between the two groups in other medical outcomes, including mortality, rehospitalization, and return to usual activities.
Schectman, J.M., Schroth, W.S., Verme, D., and Voss, J.D. (2003, October). "Randomized controlled trial of education and feedback for implementation of guidelines for acute low back pain." (AHRQ grant HS07069). Journal of General Internal Medicine 18, pp. 773-780.
This study found that an intervention based on accepted strategies of physician education, practice audit and performance feedback, and use of peer opinion leaders produced a modest but significant increase in physician practices consistent with clinical guideline recommendations for the care of patients with acute low back pain. The investigators randomized 14 physician groups with 120 primary care physicians and associate practitioners from two group model HMO practices into four groups.
The first physician education and feedback group received guideline education from recognized clinical leaders (optimal strategies for initial evaluation, testing, and treatment of acute low back pain), individual feedback about their care of acute low back pain during the past year, and feedback 6 months after the beginning of the 1-year study. The second group received copies of a videotape and pamphlet that translated guideline information into lay terms, along with two written reminders to use the materials during the study period. A third group received both interventions, and a fourth group received none. The investigators compared guideline adherence and resource use for all groups during the 12-month period before and after implementation of the acute low back pain care guideline.
Since the poorly adopted education materials had no effect, the four intervention groups were collapsed into two: clinician intervention versus no clinician intervention (control group). The clinician intervention was associated with an increase in guideline-consistent behaviors of 5.4 percent compared with a 2.7 percent decline in the control group. This was paralleled by an overall decline in raw use of services (without respect for guideline consistency) such as x-rays, magnetic resonance imaging, and subspecialty referrals of 8.5 percent in the intervention group versus 0.6 percent in the control group.
Majumdar, S.R., McAlister, F.A., and Soumerai, S.B. (2003). "Synergy between publication and promotion: Comparing adoption of new evidence in Canada and the United States." (AHRQ grant HS10391). American Journal of Medicine 115, pp. 467-472.
Promoting new evidence of a medication's effectiveness boosts physician use of that medication more than mere publication of the evidence in peer-reviewed journals. Indeed, rather than relying on the publication of articles and creation of guidelines, those wishing to accelerate the adoption of new evidence may need to undertake more active promotion, conclude the authors of this study, which was funded by AHRQ as part of the Agency's Centers for Education and Research on Therapeutics (CERTs) initiative. The researchers compared use of ramipril, an angiotensin-converting enzyme (ACE) inhibitor, by U.S. and Canadian physicians. New evidence for the drug's effectiveness was promoted in Canada by the parent company that makes ramipril, but the evidence was, for the most part, published only in peer-reviewed journals in the United States.
The Heart Outcomes Prevention and Evaluation (HOPE) study was a large trial that compared the ACE inhibitor ramipril with placebo in patients at high risk for cardiovascular events such as stroke or heart attack. It demonstrated a 22 percent reduction in cardiovascular morbidity and mortality and provided a new indication for ramipril. After adjusting for preexisting prescribing trends in both countries, ramipril prescribing increased by 12 percent per month in Canada versus 5 percent per month in the United States after the study results were presented and published. After 1 year, ramipril accounted for 30 percent of the ACE inhibitor market in Canada versus 6 percent in the United States. In Canada, promotional spending started to increase before the study's results were published; the year after publication, spending increased to $27 per physician in Canada versus $23 per physician in the United States.
In contrast, there was no promotional activity for spironolactone in either country following publication of results of a large-scale study that showed that spironolactone reduced mortality by 30 percent compared with placebo in patients with heart failure. These study results were prereleased and published in the same year and same journal as the HOPE study. In the absence of any promotional activity, publication of the spironolactone study results was associated with more modest but similar increases of 2 percent per month in spironolactone use in both countries.
Editor's Note: A related study shows that physician nonadherence to asthma medication guidelines is not uncommon during outpatient asthma visits in the United States. Another study reviews efforts to improve clinical performance in three countries via practice guidelines and other strategies. For more details, see: Ma, J. (2003, September). "U.S. physician adherence to standards in asthma pharmacotherapy varies by patient and physician characteristics." (AHRQ grant HS11313). Journal of Allergy & Clinical Immunology 112(3), pp. 633-635; and Lanier, D.C., Roland, M., Burstin, H., and Knottnerus, J.A. (2003, October). "Doctor performance and public accountability." Lancet 362, pp. 1401-1408.
Reprints of this staff-authored study (AHRQ Publication No. 04-R012) are available from the AHRQ Publications Clearinghouse.