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Patient-centered clinical decisions and their impact on physician adherence to clinical guidelines.
J Fam Pract. 1998 Apr; 46(4):311-8.JF

Abstract

BACKGROUND

This study was undertaken to assess the impact of traditionally unmeasured patient-centered factors on primary care physicians' decisions to adhere to an evidence-based clinical practice guideline for heart failure.

METHODS

Experimental and control scenarios were developed to test three patient-centered factors hypothesized to influence physician nonadherence to a heart failure guideline: patient concerns about finances, quality of life, and location of care. Each factor represented an implicit patient goal potentially in conflict with a goal of the guideline recommendations. A control scenario for one factor and an experimental scenario for a second were placed within a cross-sectional survey and questionnaires were mailed by random assignment to 978 Upstate New York family physicians. Experimental and control responses were compared by chi square.

RESULTS

The response rate was 47% (n = 456). Each hypothetical patient-centered factor resulted in significant reductions in physicians' predicted adherence. Reductions in reported pharmaceutical usage and testing of left ventricular (LV) function were associated with patient financial difficulties (P < .01). The poor quality-of-life scenario was associated with reduced testing for LV function but increased discussion of advance directives (P < .01). The clinical scenario limiting access to services for a rural patient was associated with decreases in physician choice of LV function tests and cardiology referrals (P < .05).

CONCLUSIONS

Patient-specific factors are associated with physician decisions to comply with guideline recommendations. These findings suggest that performance profiles measuring physician adherence to guidelines should be interpreted with caution, and that current case-mix methodologies may not adequately control for patient-centered factors that may influence health care quality.

Authors+Show Affiliations

Department of Family Medicine, State University of New York at Buffalo, USA. pjames@ubmedc.buffalo.eduNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

9564373

Citation

James, P A., et al. "Patient-centered Clinical Decisions and Their Impact On Physician Adherence to Clinical Guidelines." The Journal of Family Practice, vol. 46, no. 4, 1998, pp. 311-8.
James PA, Cowan TM, Graham RP. Patient-centered clinical decisions and their impact on physician adherence to clinical guidelines. J Fam Pract. 1998;46(4):311-8.
James, P. A., Cowan, T. M., & Graham, R. P. (1998). Patient-centered clinical decisions and their impact on physician adherence to clinical guidelines. The Journal of Family Practice, 46(4), 311-8.
James PA, Cowan TM, Graham RP. Patient-centered Clinical Decisions and Their Impact On Physician Adherence to Clinical Guidelines. J Fam Pract. 1998;46(4):311-8. PubMed PMID: 9564373.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Patient-centered clinical decisions and their impact on physician adherence to clinical guidelines. AU - James,P A, AU - Cowan,T M, AU - Graham,R P, PY - 1998/5/16/pubmed PY - 1998/5/16/medline PY - 1998/5/16/entrez SP - 311 EP - 8 JF - The Journal of family practice JO - J Fam Pract VL - 46 IS - 4 N2 - BACKGROUND: This study was undertaken to assess the impact of traditionally unmeasured patient-centered factors on primary care physicians' decisions to adhere to an evidence-based clinical practice guideline for heart failure. METHODS: Experimental and control scenarios were developed to test three patient-centered factors hypothesized to influence physician nonadherence to a heart failure guideline: patient concerns about finances, quality of life, and location of care. Each factor represented an implicit patient goal potentially in conflict with a goal of the guideline recommendations. A control scenario for one factor and an experimental scenario for a second were placed within a cross-sectional survey and questionnaires were mailed by random assignment to 978 Upstate New York family physicians. Experimental and control responses were compared by chi square. RESULTS: The response rate was 47% (n = 456). Each hypothetical patient-centered factor resulted in significant reductions in physicians' predicted adherence. Reductions in reported pharmaceutical usage and testing of left ventricular (LV) function were associated with patient financial difficulties (P < .01). The poor quality-of-life scenario was associated with reduced testing for LV function but increased discussion of advance directives (P < .01). The clinical scenario limiting access to services for a rural patient was associated with decreases in physician choice of LV function tests and cardiology referrals (P < .05). CONCLUSIONS: Patient-specific factors are associated with physician decisions to comply with guideline recommendations. These findings suggest that performance profiles measuring physician adherence to guidelines should be interpreted with caution, and that current case-mix methodologies may not adequately control for patient-centered factors that may influence health care quality. SN - 0094-3509 UR - https://www.unboundmedicine.com/medline/citation/9564373/Patient_centered_clinical_decisions_and_their_impact_on_physician_adherence_to_clinical_guidelines_ L2 - http://ovidsp.ovid.com/ovidweb.cgi?T=JS&amp;PAGE=linkout&amp;SEARCH=9564373.ui DB - PRIME DP - Unbound Medicine ER -