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Agency for Healthcare Research Quality

Clinical Decisionmaking

Studies show low physician adherence to clinical guidelines for managing pneumonia and heart disease

Electronic medical record systems and computer-based reminders have been cited as ways to improve physicians' compliance with evidence-based clinical practice guidelines. However, a new study supported by the Agency for Healthcare Research and Quality found that other factors, such as physician specialty and attitudes toward guidelines, also affect use of guidelines for managing pneumonia. Another AHRQ-supported study showed that computer-generated guidelines for managing heart disease failed to improve physicians' and pharmacists' adherence to the guidelines. The studies are discussed here.

Switzer, G.E., Halm, E.A., Chang, C., and others (2003, October.) "Physician awareness and self-reported use of local and national guidelines for community-acquired pneumonia." (HS08282) Journal of General Internal Medicine 18, pp. 816-823.

This survey of 352 physicians who managed patients with community-acquired pneumonia (CAP) at seven Pittsburgh hospitals revealed low levels of awareness and use of clinical guidelines for managing CAP. Overall, 48 percent of the doctors reported being influenced by American Thoracic Society (ATS) guidelines, but only 20 percent reported using these guidelines. Also, 48 percent of doctors were uncertain whether a local (hospital-developed) CAP guideline existed, and only 28 percent of physicians who knew a local guideline existed said that they frequently used the guideline.

Three variables were independently associated with use of ATS guidelines: practicing as a pulmonary or infectious disease specialist, spending more time on nonpatient-related activities such as teaching, and scoring higher on the personality trait "intellect." Use of local guidelines was negatively associated with practice as an infectious disease or pulmonary medicine specialist and positively associated with positive attitudes toward practice guidelines. The researchers conclude that more effective implementation strategies will be necessary to encourage compliance with practice guidelines for the management of CAP.

Tierney, W.M., Overhage, J.M., Murray, M.D., and others (2003, December). "Effects of computerized guidelines for managing heart disease in primary care." (HS07763). Journal of General Internal Medicine 18, pp. 967-976.

Although interventions such as computer reminders have increased adherence to preventive care guidelines, there is less experience with their use in managing chronic illnesses, and their effects have been inconsistent. For example, this study found that patient-specific care suggestions for managing heart disease in primary care, which were generated by a sophisticated electronic medical record system, failed to improve physicians' and pharmacists' adherence to accepted practice guidelines or outcomes of heart disease patients.

The researchers randomized physicians and pharmacists to either intervention or control groups. Using data from each patient's electronic medical record and data entered by the physicians (for example, vital signs and symptoms), the workstation generated patient-specific, guideline-based cardiac care suggestions for 706 patients (with heart failure and/or ischemic heart disease) of intervention physicians and pharmacists. For patients in the physician and pharmacist control group, these suggestions were withheld.

Patients were followed for 1 year, during which they made 3,419 primary care visits and were eligible for 2,609 separate cardiac care suggestions. The computer-generated guidelines had no significant effect on physicians' or pharmacists' adherence to the care suggestions or on any patient outcome. The physicians and pharmacists may have found the intervention intrusive and time consuming. On the other hand, the system may have been more powerful if it required physicians to either comply with each suggestion or document their reasons for not complying.

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