Transcript Cabana MD, et al. Why don`t physicians follow

Facilitators and Barriers to Application of
Low Back Pain Clinical Guidelines
Alan K. Novick, MD
Rehabilitation Medical Director
Memorial Rehabilitation Institute
Objectives
Develop a basic understanding of the Agree II tool with
respect to “Applicability”
Develop an understanding of potential barriers and
obstacles to application of LBP clinical guidelines
including financial and societal
Develop a knowledge of potential facilitators to apply
LBP clinical guidelines
Disclosures
I have no financial disclosures
AGREE II Tool
Score
– 1 to 7
1= Strongly Disagree
7= Strongly Agree
23 Items
6 Domains
AGREE II Tool
AGREE II Domain 5: Applicability
Guideline
18
19
20
21
Avg
NASS Spinal Stenosis
2.25
2.25
2.0
2.75
5.5
NASS Deg Spondylolithesis
1.8
1.2
1.0
3.4
6.0
AAOS Symptomatic Osteoporosis comp fx
1.33
3.0
1.33
2.33
6.0
APT: LBP CPGs linked to the ICF
1.6
2.8
.8
2.2
3.2
Cabana MD, et al. Why don't physicians follow clinical
practice guidelines? A framework for improvement.
JAMA. 1999 Oct 20;282(15):1458-65.
– Review of 78 published studies describing at
least 1 barrier
Knowledge
– Lack of awareness n=46
Attitudes
–
–
–
–
Lack of agreement n=33
Lack of self-efficacy n=19
Lack of outcome expectancy n=8
Lack of motivation n=14
Behavior
– External Barriers n=34
Patient
Guideline
Enviromental
Cabana MD, et al. Why don't physicians follow clinical
practice guidelines? A framework for improvement.
JAMA. 1999 Oct 20;282(15):1458-65.
Lack of awareness
– Volume of information
Lack of agreement
– Too cookbook, Too rigid
– Interpretation of evidence
Lack of self-efficacy
– Belief that physician can’t perform CPG
Lack of outcome expectancy
– Belief that CPG will not lead to desired outcome
Lack of motivation
– Inertia of previous practice habits
Cabana MD, et al. Why don't physicians follow clinical
practice guidelines? A framework for improvement.
JAMA. 1999 Oct 20;282(15):1458-65.
External Barriers
– Patient
Inability to reconcile patient preferences
– Guideline
Presence of contradictory guidelines
– Environmental
Lack of time, resources
organizational constraints
Perceived increase in malpractice liability
Ayres CG, Griffith HM. Perceived barriers to and facilitators
of the implementation of priority clinical preventive services
guidelines. Am J Manag Care. 2007 Mar;13(3):150-5.
Focus groups from health plan providers
– Barriers
Payment and Cost
Time
Legal Issues
Inconsistency among HP tools
Lack of internalization
Patient-clinician relationship
– Facilitators
HP support
Patient Materials
Clinician awareness
HP tool consistency
Légaré F, et al. Barriers and facilitators to implementing
shared decision-making in clinical practice: update of a
systematic review of health professionals' perceptions.
Patient Educ Couns. 2008 Dec;73(3):526-35.
38 studies, 3231 participants, 89% physicians
– Barriers
Time constraints (22/38)
Lack of applicability due to patient characteristics
(18/38)
Clinical situations (16/38)
– Facilitators
Provider Motivation (23/38)
Positive impact on the clinical process (16/38)
Patient outcomes (16/38)
Barriers: LBP CPG’s
Lack of defined group of practitioners
– Ortho, Neurosurgery, PM&R, Rheumatology,
Anesthesiology and Primary Care may all
treat back pain
Different clinical approaches
Challenging to get consensus or distribute CPGs
Barriers: LBP CPG’s
Financial
– Cost of treatment
– Resource Utilization
HMO may require conservative treatment prior to
diagnostic testing
NASS Spinal Stenosis CPG
Barriers: LBP CPG’s
Financial
– Cost of treatment
– Resource Utilization
HMO may require conservative treatment prior to
diagnostic testing
– Evidence inconclusive for pharmacologic or therapeutic
treatments
– MRI appropriate diagnostic test
– May be unable to order MRI until fails conservative
treatment
– Economic Incentives
Physician ownership/profitability
– Imaging & therapy centers, dispensary
Barriers: LBP CPG’s
Resource Availability
– Sufficient practitioners with skills to deliver the
recommended care
– Sufficient equipment
Clinical Practice Guideline
– Structure variability
– Size
Barriers: LBP CPG’s
Societal
– Patient expectations
Patients often want certain treatments/testing
(MRI, medications, etc.)
Patient satisfaction
– May impact physician scorecard/reviews
Web based physician rating sites
Employed physician compensation
Barriers: LBP CPG’s
Societal
– Liability
Defensive medicine
Facilitators: LBP CPG’s
Facilitators: LBP CPG’s
Research
Consensus between specialties
Input from all stakeholders
– Patients
– Multiple specialists
– Imaging centers/therapy centers
Standardization of CPGs
Tools for implementation
Distribution of Information
– Website postings of CPGs
Conclusion