Patient Safety and Quality

Adequate financial bonuses and peer support motivate providers to adhere to evidence-based treatment guidelines

Providers vary in their adherence to evidence-based clinical guidelines for treating different medical conditions. Mere dissemination of clinical guidelines does not assure physician adherence. Personal and systemwide factors often predispose providers toward greater or less adherence to evidence-based treatment guidelines. A new study found that primary care providers who perceived the financial bonus they received for performing recommended practices was adequate (financial salience) were nearly four times more likely to follow treatment guidelines. Also, those who perceived peer support in the patient-care process were twice as likely to follow recommended clinical guidelines for four conditions studied.

Provider perceptions of the health maintenance organization's threat to their clinical autonomy and control were associated with less guideline adherence, according to a team of researchers led by Anthony C. Waddimba, M.D., of Boston University. The researchers surveyed 186 primary care providers about their attitudes associated with adherence in a managed care setting that had implemented a pay-for-performance (P4P) initiative with explicit financial bonuses for guideline adherence and a punitive financial withhold for nonadherence. One-third of the participants had received a P4P bonus by the time of the survey. Factors measured by the survey included personal attitudes, subjective/social norms, perceived behavior control, and physician characteristics.

Clinical guideline adherence was computed as the percentage of services delivered out of those expected according to the guideline for each of four conditions: asthma, otitis media, sinusitis, and diabetes. For example, the diabetes care guideline required urine microalbumin screening, two annual glycohemoglobin tests, one annual LDL cholesterol assay, influenza vaccination, and an annual dilated eye exam. Across the four clinical conditions, the mean guideline adherence rate was 59 percent in 2001 and 55 percent in 2005. This study was supported by the Agency for Healthcare Research and Quality (HS16832).

See "Provider attitudes associated with adherence to evidence-based clinical guidelines in a managed care setting," by Dr. Waddimba, Mark Meterko, Ph.D., Howard B. Beckman, M.D., and others in the February 2010 Medical Care Research and Review 67(1), pp. 93-116.

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