Internists' Attitudes about Clinical Practice Guidelines

Documentation of unexplained geographic variations in medical practices [1] and use of interventions inappropriately [2] or before their effectiveness has been established [3] has led to the rapid proliferation of clinical practice guidelines. These systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances [4] are an attempt to discourage ineffective medical practices, encourage effective practices, and improve health outcomes [5-10]. Despite increasing enthusiasm for guidelines, evidence exists that guidelines often do not affect clinical practices or health outcomes [11-17]. One possible obstacle to effective guideline implementation is physician concern about the intent and validity of these documents [18-22]. Many physicians first encounter guidelines in the context of peer review, utilization management, and quality control programs, experiences that they may not perceive positively. Such outsider scrutiny is considered by some to be a challenge to autonomous clinical decision making. Little systematic study of physicians' attitudes toward guidelines, however, has been done [23, 24]. We did a national survey of a random sample of American College of Physicians (ACP) members to assess ACP members' familiarity with, confidence in, and attitudes about guidelines issued by ACP and other organizations and members' perceptions of the effect of ACP and other guidelines on their practices. Methods Questionnaire We designed a practice guidelines questionnaire that sought information about 1) demographic and professional characteristics of responders, including their year of graduation from medical school, board certification, academic affiliations, hours per week devoted to patient care, practice type, practice setting, and the principal method of clinical reimbursement; 2) responders' ratings of their familiarity with and confidence in practice guidelines issued by ACP, various medical specialty societies, and other major health care organizations; 3) responders' attitudes regarding guidelines and their effects on medical care; 4) any change in responders' clinical practice during the last year as a result of guidelines; and 5) responders' ratings of the importance of practice guidelines and other sources of information for clinical decision making. The questionnaire was approved by the ACP Clinical Efficacy Assessment Subcommittee (CEAS) after it was pilot-tested with 80 primary care physicians affiliated with the Johns Hopkins Health Plan [25] and 95 volunteers at the 1991 ACP Annual Meeting. Familiarity with, confidence in, and attitudes about guidelines were assessed using 5-point ordinal scales, with anchors appropriate to the judgment requested (for example, 5 = very familiar to 1 = not familiar; 5 = great confidence to 1 = no confidence). Estimated effects of guidelines on various aspects of medical practice were scored as likely to decrease, to have no effect, and likely to increase Sample We drew a stratified random sample of 400 associates, 1000 general internists, and 1200 internist specialists from ACP membership records. Members with specialty certification were oversampled because their response rate to previous ACP surveys was lower than that of other members. (Johnson White L. Personal communication.) The total sample of 2600 physicians represented 3.5% of the ACP membership and included internists from every state. The sample size for the survey was based on assumptions of a response rate of 65% and a 2-point standard deviation on the 5-point ordinal scales that comprised most items in our survey. Under these assumptions, a sample size of 2600 gave us greater than 90% power to detect a 1-point difference for comparisons involving the smallest subspecialty groups (for which we expected about 100 responders). Survey Procedure The survey was mailed in December 1991, accompanied by a letter from the executive vice-president of ACP encouraging participation in the survey. Follow-up mailings were sent to nonresponders 1 and 2 months later, and data collection was terminated 6 weeks after the third mailing. Each physician was assigned a number that was placed on the cover sheet of mailed questionnaires. The same number was used to access information in an ACP membership database about physician year of graduation, specialty certification, practice location, and membership status. Cover sheets were removed from returned questionnaires after recording the identification number. In this way, we were able to identify nonresponders, compare demographic characteristics of responders and nonresponders, and preserve the anonymity of physicians during data abstraction and analysis. Analysis Data from returned questionnaires were double-entered and audited. Self-reported year of graduation and subspecialty certification were compared with information obtained from ACP databases, with statistics of 0.98 and 0.53, respectively. The low for subspecialty certification resulted from responders reporting a qualification that was not in ACP files. Many physicians join ACP before completing their specialty training, and ACP has not previously updated its files for specialty status more often than once every 3 years. Therefore, we used self-reported professional characteristics from our survey in our analysis. To compensate for oversampling of subspecialists and undersampling of Associate ACP members, the ratio of the proportion of Associates, generalists, and specialists in the final sample to their true proportion in the ACP membership was used to generate adjustment weights that were applied to all analyses. Questions answered by fewer than 90% of responders were not considered in the analysis. Frequency distributions of responses to questionnaire items were examined before statistical tests were selected and applied. Physician characteristics were coded as dichotomous variables except for year of graduation, which was recoded into four categories. We then tested the statistical significance of associations between physician characteristics and dichotomous question responses (for example, impact compared with no impact on clinical practice) using the chi-square test. For items with 5-point response scales, we tested the statistical significance of differences between ratings for different physician subgroups using analysis of variance. Stepwise logistic and multiple linear regression models were used to explore relations between sets of physician characteristics and responses to individual questions. Given the multiple comparisons, differences in response distributions between physician subgroups were considered statistically significant at the P 0.005 level. We developed an overall measure of physician attitudes toward guidelines by summing ordinal scale ratings regarding four positive views of guidelines (strength of agreement with statements that guidelines generally are good educational tools, unbiased syntheses of expert opinion, a convenient source of advice, and intended to improve quality of care) and the inverse of ordinal ratings regarding four negative views of guidelines (oversimplified or cookbook medicine, a challenge to physician autonomy, too rigid to apply to individual patients, and intended to cut costs). Possible scores ranged from 8 to 40, with 40 representing the most positive attitudes about guidelines. The internal consistency coefficient (Chronbach ) for this scale was 0.76. Results Description of Responders and Nonresponders Of the 2600 physicians in our original sample, 35% returned questionnaires after the first mailing, 18% after the second mailing, and 8% after the third mailing. Eighty-seven physicians from the original sample were determined to be ineligible because of death (n = 5), retirement (n = 48), survey damage (n = 1), or no forwarding address (n = 33). Thus, we received completed questionnaires from 1513 (60%) of 2513 eligible physicians. Characteristics of those who did and did not respond to the survey were compared using data available from the ACP membership file. Responders and nonresponders were similar in terms of their year of graduation from medical school, geographic location of practice, and prevalence of generalist and subspecialty certification in internal medicine (Table 1). In addition, the characteristics of responders were similar to those of the target population of College members, after adjustment for intentional oversampling in some strata (Table 2). Table 1. Characteristics of Members of the American College of Physicians: Survey Responders and Nonresponders Table 2. Professional Characteristics of Survey Responders* Familiarity with Guidelines The percentage of responders reporting that they were familiar (4 or 5 on a scale of 1 = not at all familiar to 5 = very familiar) with the content of selected guidelines varied from 11% for ACP exercise stress test guidelines to 59% for National Cholesterol Education Program (NCEP) guidelines (Table 3). Ratings of familiarity with guidelines that have actually been published were significantly greater than ratings for a fictitious ACP guideline about computed tomography of the head (mean score, 1.8 of 5; P < 0.001 for comparison with mean score for any of the other guidelines), which was included in the survey to provide a measure of the degree to which familiarity scores might be inflated because of a general desire to appear knowledgeable. The responders who reported familiarity with this nonexistent guideline (7% of total) provide a baseline for interpretation of the familiarity reported for the other guidelines. Table 3. Responders' Familiarity with Selected Clinical Practice Guidelines by Responder Specialty Subspecialists were more likely to report familiarity with guidelines pertaining to their own subspecialty than with those pertaining to other subspecialties or to general medical practice. For example, board-certified