Hospital Topical Law

Clinical practice guidelines can potentially lead to reductions in healthcare costs and improved patient outcomes if adopted by physicians into their clinical practice. This research study provides data that gives healthcare administrators a basic understanding of how physicians perceive clinical practice guidelines (CPGs) and gives practical suggestions to obtain physician adherence to CPGs.     

Does attribution theory explain physicians' nonacceptance of clinical practice guidelines?

Clinical practice guidelines can potentially lead to reductions in healthcare costs and improved patient outcomes if adopted by physicians into their clinical practice. This research study provides data that gives healthcare administrators a basic understanding of how physicians perceive clinical practice guidelines (CPGs) and gives practical suggestions to obtain physician adherence to CPGs.     

Clinical practice guidelines and organizational adaptation: a framework for analyzing economic effects

OBJECTIVES: The overall objective of this article was to review the theoretical and conceptual dimensions of how the implementation of clinical practice guidelines (CPGs) is likely to affect treatment costs. METHODS: An important limitation of the extant literature on the cost effects of CPGs is that the main focus has been on clinical adaptation. We submit that the process innovation aspects of CPGs require changes in both clinical and organizational dimensions. We identify five organizational factors that are likely to affect the relationship between CPGs and total treatment costs: implementation, coordination, learning, human resources, and information. We review the literature supporting each of these factors. RESULTS: The net organizational effects of CPGs on costs depends on whether the cost-reducing properties of coordination, learning, and human resource management offset potential cost increases due to implementation and information management. CONCLUSIONS: Studies of the cost effects of clinical practice guidelines should attempt to measure, to the extent possible, the effects of each of these clinical and organizational factors.     

Family physicians' opinions and attitudes to three clinical practice guidelines

BACKGROUND: Clinical practice guidelines (CPGs) have been promoted as a strategy to measure and improve the quality of patient care. However, more effort has been expended on creating guidelines than implementing them. We surveyed family physicians about their knowledge of and attitudes toward 3 well-publicized CPGs. METHODS: A survey questionnaire was sent to a national sample of 600 family physicians selected at random from a file from the American Academy of Family Physicians (AAFP). RESULTS: After 2 mailings, the response rate was 71%. For each of the 3 guidelines, roughly 60% of respondents were familiar or somewhat familiar with the CPG. More than half of family physicians studied said they have changed their medical practices based on CPGs, and only 3% said they do not believe in guidelines and would not use them. Use of CPGs was lowest among physicians in solo practice and among those working in rural areas. However, no significant differences in CPG use or familiarity were noted based on number of years in practice. Many respondents indicated an interest in keeping CPGs current via the internet. CONCLUSIONS: Most American family physicians find CPGs to be helpful, and familiarity with them is fairly uniform across most subgroups studied.     

Making decisions about cancer screening when the guidelines are unclear or conflicting

OBJECTIVE: Our purpose was to determine the factors involved in the cancer screening decisions of family physicians in situations where the clinical practice guidelines are unclear or conflicting as opposed to when they are clear and uncontroversial. STUDY DESIGN: We analyzed discussions with focus groups using a constant comparative approach. POPULATION: A total of 73 family physicians in active practice participated in 10 focus groups (1 urban group and 1 rural group in each of 5 Canadian provinces). OUTCOME MEASURES: Our main outcome measures were participants' perceptions regarding cancer screening when the guidelines were unclear or conflicting. RESULTS: We propose a model of the determinants of cancer screening decision making with regard to unclear and conflicting guidelines. This model is rooted in the physician-patient relationship, and is an interactive process influenced by patient factors (anxiety, expectations, and family history) and physician factors (perception of guidelines, clinical practice experience, influence of colleagues, distinction between the screening styles of specialists and family physicians, and the amount of time and financial costs involved in performing the maneuver). CONCLUSIONS: Our model is unique, because it is embedded in the physician-patient relationship. Ultimately, a modified model could be used to design interventions to assist with the implementation of preventive services guidelines.     

Do clinical practice guidelines reflect research evidence?

OBJECTIVES: To examine whether existing clinical practice guidelines (CPGs) for cholesterol testing reflect research evidence and hence may control or reduce costs while maintaining or improving the quality of care. METHODS: A systematic search for published and unpublished cholesterol testing CPGs and independent critical appraisal of the CPGs by two researchers using a standard checklist. RESULTS: In four of the five CPGs analysed, the link between the research evidence and the recommendations was not maintained. The appraisal, local experience and the literature all suggest that panel composition is an important explanation, in that the greater the involvement of clinical experts in the development process of the CPGs, the less the recommendations reflected the research evidence. Even though their participation is important for CPG uptake, clinical expert panels appear to have difficulty limiting CPGs to research-based recommendations. CONCLUSIONS: Existing cholesterol testing CPGs are unlikely to improve the quality of care while controlling or reducing costs. The problem lies not with guideline implementation but with the guidelines themselves. It is unclear how best to ensure that recommendations reflect research evidence but this is likely to require significant and progressive changes to the current guideline development process, including a redefinition of the clinical experts' role.     

Gender bias in shared decision-making among cancer care guidelines: A systematic review

Background

In cancer care, the promotion and implementation of shared decision-making in clinical practice guidelines (CPG) and consensus statements may have potential differences by gender.

Objective

To systematically analyse recommendations concerning shared decision-making in CPGs and consensus statements for the most frequent cancers exclusively among males (prostate) and females (endometrial).

Search Strategy

We prospectively registered the protocol at PROSPERO (ID: RD42021241127). MEDLINE, EMBASE, Web of Science, Scopus and online sources (8 guideline databases and 65 professional society websites) were searched independently by two reviewers, without language restrictions.

Inclusion Criteria

CPGs and consensus statements about the diagnosis or treatment of prostate and endometrial cancers were included from January 2015 to August 2021.

Data Extraction and Synthesis

Quality assessment deployed a previously developed 31-item tool and differences between the two cancers analysed.

Main Results

A total of 176 documents met inclusion criteria, 97 for prostate cancer (84 CPGs and 13 consensus statements) and 79 for endometrial cancer (67 CPGs and 12 consensus statements). Shared decision-making was recommended more often in prostate cancer guidelines compared to endometrial cancer (46/97 vs. 13/79, 47.4% vs. 16.5%; p < .001). Compared to prostate cancer guidelines (mean 2.14 items, standard deviation 3.45), compliance with the shared-decision-making 31-item tool was lower for endometrial cancer guidelines (mean 0.48 items, standard deviation 1.29) (p < .001). Regarding advice on the implementation of shared decision-making, it was only reported in 3 (3.8%) endometrial cancer guidelines and in 16 (16.5%) prostate cancer guidelines (p < .001).

Discussion and Conclusions

We observed a significant gender bias as shared decision-making was systematically more often recommended in the prostate compared to endometrial cancer guidelines. These findings should encourage new CPGs and consensus statements to consider shared decision-making for improving cancer care regardless of the gender affected.

Patient or Public Contribution

The findings may inform future recommendations for professional associations and governments to update and develop high-quality clinical guidelines to consider patients' preferences and shared decision-making in cancer care.     

Health policy issues and applications for evidence-based medicine and clinical practice guidelines

Evidence-based medicine and clinical practice guidelines have become increasingly salient to the international health care community in the 1990s. Key issues in health policy in this period can be categorised as costs and access to care, quality of and satisfaction with care, accountability for value in health care, and public health and education. This paper presents a brief overview of evidence-based medicine and clinical practice guidelines and describes how they are likely to influence health policy. Evidence-based medicine focuses on the use of the best available clinical (efficacy) evidence to inform decisions about patient care; guidelines are statements systematically developed from efficacy and effectiveness research and clinical consensus for practitioners and patients to use in making decisions about appropriate care under different clinical circumstances. Both fields have developed methods for evaluating and synthesising available evidence about the outcomes of alternative health care interventions. They have clear implications for health policy analysts: greater reliance should be placed on scientific evidence, policy decisions should be derived systematically, and health care decisionmaking must allow for the active participation of health care providers, policy makers, and patients or their advocates. The methods and information generated from evidence-based guidelines efforts are critical inputs into health policy analysis and decision-making.     

Who decides about prostate cancer treatment? A qualitative study

BACKGROUND: Shared decision-making between patients and health professionals has been promoted as ethically and clinically desirable. Patients vary in their willingness to participate in decision-making, while clinicians identify practical barriers to greater participation, such as time and communication skills. A paternalistic approach to treatment decisions remains common even in an area of clinical uncertainty. The willingness of patients to participate in decision-making varies over time during the course of an illness but patients may not be given the opportunity to revisit clinical decisions with their specialists after the initial consultation. OBJECTIVES: To gain an in depth understanding of the perspectives of men recently diagnosed with localized prostate cancer, and to explore the value of decision-making models in the setting of NHS practice. METHODS: The study design was a qualitative analysis of semi-structured interviews. Nineteen men recently diagnosed with localized prostate cancer were included from patients attending a British District General Hospital. RESULTS: The interviews suggested that the respondents' treatment plans were mostly decided on their behalf by their clinicians. Whilst initially accepting this paternalistic approach, the interviewees over time wished to revisit the decisions. Patients' barriers to shared decision-making included fear of appearing disrespectful to their doctors and of taking responsibility for the outcome of treatment. The structure of patient follow-up did not afford the men an opportunity to discussion treatment decisions further. CONCLUSIONS: The paternalistic decision-making model remains the chosen approach in this situation. The patients' willingness to become actively involved in choosing their care varies over time. Barriers to shared decision-making can be identified both in the nature of the doctor-patient relationship and the structure of the clinical follow-up.     

Practice guidelines for medical treatment from the perspective of health law

Clinical practice guidelines are directions for medical doctors on the action to be taken in a given situation, thus standardising medical performance as regards content. The implementation of clinical practice guidelines (CPGs) is stimulated by government and health care insurers. Court decisions frequently refer to these guidelines. From a medical and legal perspective, the implementation of CPGs in daily medical practice has advantages (e.g. they contribute to best medical practice as well as to the quality of information to be provided to the patients), but also disadvantages (they may replace professional responsibility and may put cost containment over professional autonomy). CPGs may contribute to quality of care provided they are applied flexibly and responsibly.     

Clinical practice guidelines and patient decision aids. An inevitable relationship

As health professionals and patients are moving toward shared models of decision making, there is a growing need for integrated decision support tools that facilitate uptake of best evidence in routine clinical practice in a patient-centered manner. This article charts the landscape of clinical practice guidelines (CPGs) and patient decision aids. Decision support tools for medical practice can be mapped on two dimensions. (1) The target user and his or her level of decision making; either for groups of patients or for an individual patient and (2) the level of uncertainty: either supporting more directive decision making (behavior support) in the case of strong recommendations with a single best option or supporting dialog (deliberation support) on the pros and cons of different options in the case of conditional (or weak) recommendations. We conclude that it is important to establish closer links between CPGs and patient decision aids, through collaborative development of both. Such collaboration will encourage the design of decision support tools for professionals and patients who share the same evidence and the aim to increase the quality of decision making between doctor and patient. This could facilitate the implementation of CPGs and shared decision making in clinical practice.     

Motivating physician behaviour change: social influence versus financial contingencies

The recent development of clinical practice heuristics is a logical consequence of outcomes and effectiveness research. Proponents of clinical practice guidelines (CPGs) believe they will lower costs, enhance quality, and reduce the incidence of malpractice claims. Although the process for generating CPGs appears relatively uncomplicated, guidelines alone do not produce lasting changes in physician behaviour. Discusses strategies for implementing CPGs based on the various factors that influence physician behaviour. Recommends direct behaviour management strategy based on financial contingencies.     

Rural/urban differences in accounts of patients' initial decisions to consult primary care

In the UK, patients in urban areas consult primary health care more than rural patients for both trivial and serious conditions. This study, involving focus groups and interviews, examined rural/urban differences in accounts of patients' intentions around initial decisions to consult general practice. Findings suggest 'relationships' between doctors and patients and easier access to appointments could affect consulting in rural areas, while decision-making for urban patients tended to be more consumerist. Perceptions about access to different health services meant rural patients' decision-making in out-of-hours emergencies was complex. Rural/urban differences in demand could be affected by change in UK primary care provision.     

Evolution of physicians' attitudes towards practice guidelines

OBJECTIVES: To assess changes in physicians' attitudes towards practice guidelines and towards the role of empirical evidence in their development. METHODS: The findings from two surveys carried out in 1993 and 1997 on the same random sample from two Italian medical specialty societies were compared. In both studies, physicians were mailed a questionnaire asking their views on the goals and role of practice guidelines in influencing clinical decision-making, and the role of empirical evidence versus subjective clinical experience in their development. RESULTS: One hundred and seventy physicians participated in both surveys. An increasing proportion of physicians accepted that cost containment could be a legitimate goal of practice guidelines (from 26% in 1993 to 40% in 1997; P = 0.010). More clinicians (43% in 1993 and 57% in 1997; P < 0.01) supported the use of empirical evidence, as opposed to subjective clinical experience, as the primary basis for practice guidelines. Although only a tiny minority of physicians (6% in 1993 and 1997) supported the view that practice guidelines should reflect patient preferences, an increased proportion of physicians supported the participation of representatives from outside the medical profession in their development. The level of support increased from 6% in 1993 to 26% in 1997 (P < 0.001) in the case of consumers, from 24% to 38% (P = 0.015) for patient involvement and from 16% to 33% (P = 0.003) in the case of health care administrators. CONCLUSIONS: The documented changes suggest that more clinicians acknowledge the role of empirical evidence and the need for a dialogue with other professionals and patient groups in the development of practice guidelines than was the case in the recent past.     

Health care system and insurer support for smoking cessation guideline implementation

Physician use of clinical practice guidelines (CPGs) is disappointingly low in the United States. Much emphasis historically has been placed on the individual clinician to implement use of guidelines in practice. Recently, the Public Health Service issued an updated set of smoking cessation guidelines that include recommendations not only for patients and physicians, but also for health care administrators, insurers, and purchasers. A random sample of Missouri family physicians and general internists was used to determine, for the first time empirically, whether physicians receiving external support for guideline implementation were more likely to adopt and adhere to guidelines in practice. Fewer than 20 percent of physicians receive system support consistent with the updated guideline for smoking cessation. Only 32 percent of physicians who are unaware of the guidelines receive any of the recommended external support, while nearly 60 percent of physicians who adhere to the guidelines in practice are receiving some form of external support. Thus, the fundamental issue that requires national attention is that successful guideline implementation is highly dependent on administrative supports from health care organizations and insurers.     

A shared treatment decision-making approach between patients with chronic conditions and their clinicians: the case of diabetes

In this paper, we discuss the Charles et al. approach to shared treatment decision-making (STDM) as applied to patients with chronic conditions and their clinicians. We perceive differences between the type of treatment decisions (e.g. end-of-life care, surgical treatment of cancer) that generated existing approaches of shared decision-making for acute care conditions (including the Charles et al. model) and the treatment decisions that patients with chronic conditions need to make and revisit on an ongoing basis. For instance, treatment decisions in the chronic care setting are more likely to require a more active patient role in carrying out the decision and to offer a longer window of opportunity to make decisions and to revisit and reverse them without important loss than acute care decisions. The latter may require minimal patient participation to realize, are often urgent, and may be irreversible. Given these differences, we explore the applicability of the Charles et al. model of STDM in the chronic care context, especially chronic care that relies heavily on patient self-management (e.g. diabetes). To apply the Charles et al. model in this clinical context, we suggest the need to emphasize the patient-clinician relationship as one of partners in making difficult treatment choices and to add a new component to the shared decision-making approach: the need for an ongoing partnership between the clinical team (not just the clinician) and the patient. In the last section of the paper, we explore potential healthcare system barriers to STDM in chronic care delivery. Throughout the discussion we identify areas for further research.     

Not of one mind: mental models of clinical practice guidelines in the Veterans Health Administration

OBJECTIVE: The purpose of this paper is to present differences in mental models of clinical practice guidelines (CPGs) among 15 Veterans Health Administration (VHA) facilities throughout the United States. DATA SOURCES: Two hundred and forty-four employees from 15 different VHA facilities across four service networks around the country were invited to participate. Participants were selected from different levels throughout each service setting from primary care personnel to facility leadership. STUDY DESIGN: This qualitative study used purposive sampling, a semistructured interview process for data collection, and grounded theory techniques for analysis. DATA COLLECTION: A semistructured interview was used to collect information on participants' mental models of CPGs, as well as implementation strategies and barriers in their facility. FINDINGS: Analysis of these interviews using grounded theory techniques indicated that there was wide variability in employees' mental models of CPGs. Findings also indicated that high-performing facilities exhibited both (a) a clear, focused shared mental model of guidelines and (b) a tendency to use performance feedback as a learning opportunity, thus suggesting that a shared mental model is a necessary but not sufficient step toward successful guideline implementation. CONCLUSIONS: We conclude that a clear shared mental model of guidelines, in combination with a learning orientation toward feedback are important components for successful guideline implementation and improved quality of care.     

Exploring the decision-making preferences of people with colorectal cancer

OBJECTIVES: To explore patient views on participation in treatment, physical care and psychological care decisions and factors that facilitate and hinder patients from making decisions. DESIGN: Qualitative study using semi-structured interviews with patients. SETTING AND PARTICIPANTS: Three NHS Trusts in the north-west of England. Theoretical sampling including 41 patients who had been treated for colorectal cancer. RESULTS: For patients, participation in the decision-making process was about being informed and feeling involved in the consultation process, whether patients actually made decisions or not. The perceived availability of treatment choices (surgery, radiotherapy, chemotherapy) was related to type of treatment. Factors that impacted on whether patients wanted to make decisions included a lack of information, a lack of medical knowledge and trust in medical expertise. Patients perceived that they could have a more participatory role in decisions related to physical and psychological care. CONCLUSION: This study has implications for health professionals aiming to implement policy guidelines that promote patient participation and shared partnerships. Patients in this study wanted to be well informed and involved in the consultation process but did not necessarily want to use the information they received to make decisions. The presentation of choices and preferences for participation may be context specific and it cannot be assumed that patients who do not want to make decisions about one aspect of their care and treatment do not want to make decisions about other aspects of their care and treatment.     

The combined effects of participatory styles of elderly patients and their physicians on satisfaction

OBJECTIVES: To test whether concordance or discordance of patient participation between patients and physicians is associated with higher satisfaction, and to examine the effects of patients' and physicians' participatory styles on patients' satisfaction with their physicians. DATA: Data collected in the Texas Tech 5000 Survey of elderly patients in West Texas were used. Patient satisfaction with their physicians was measured by a single item from the Consumer Assessment of Health Plans (CAHPS), representing patients' ratings of their physicians. Patient participation was measured by an index derived from a three-item instrument and physicians' participatory decision-making (PDM) style was measured by a three-item instrument developed by the Medical Outcomes Study. METHODS: An ordered logit multivariate regression was used to investigate the effects of patients' and physicians' participatory styles on satisfaction with physicians. The interaction between patients' participation and physicians' participatory styles was also included to examine the dependency of the two variables. RESULTS: Controlling for confounding factors, a higher PDM score was associated with a higher rating of patient satisfaction with physicians. A higher patient participation score was related to a lower physician satisfaction rating. The combined effect of patients' and physicians' participation styles indicated that for a low patient participation score, a high PDM score was not needed to produce high satisfaction. The greater the discordance in this direction, the higher the satisfaction. However, with a high patient participation score, only an extremely high PDM score would produce relatively high satisfaction. CONCLUSIONS: The current study supports the discordance hypothesis. Participatory physicians and patient-physician communications concerning patient participation can promote higher satisfaction.