Doctors may not follow practice guidelines, study finds.

Doctors may be unaware of or unable to follow established clinical practice guidelines, according to a study recently reported in the Journal of the American Medical Association.

Meant to improve medical care by compiling what panels of experts consider to be best practices in a given field, "clinical practice guidelines are systematically defined statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances," according to the National Academy of Sciences Institute of Medicine.

The standard of care is usually an issue for plaintiff attorneys involved with medical negligence suits. "What's new," said Doug Peters, an attorney in Detroit who tries these cases, "is that the profession has apparently ... discovered that physicians aren't following practice guidelines intended to maintain a minimum standard of care."

The study findings may also be significant, said Peters, because "medical malpractice insurers, especially for specialty and physician-owned practices, are requiring compliance with standards and guidelines from credible agencies."

The study, which analyzed 120 physician surveys taken between 1966 and 1998, noted that guidelines have had a limited effect on changing physician behavior and that doctors' adherence to guidelines may be hindered by a variety of barriers.

The study found

* at least 10 percent of doctors were unaware of a particular guideline that pertained to their practice;

* at least 10 percent more were probably aware of a guideline but were not familiar enough with it to be able to follow it; and

* another group knew of a guideline but refused to follow it for reasons including a belief that compliance would expose patients to unjustifiable risk. Some doctors also reported resenting a "cookbook" approach to patient care.

Barriers to guideline adherence noted by the study included physician attitudes (disagreement with a specific guideline or the concept of guidelines in general); self-efficacy (whether a physician believes he or she is capable of performing a behavior); the expectation that a given behavior will lead to a particular consequence; and the inertia of previous practice.

External barriers include patient, guideline, and environmental factors. For example, patients may resist or perceive no need for guideline recommendations. Some doctors described guidelines as difficult to use when asked about them hypothetically. And changes not under physician control, such as acquisition of new resources or facilities, insufficient staff, and increased practice costs, also act as barriers to adherence.

Since clinical practice guidelines are not fixed protocols that must be followed but are intended for health care professionals and providers to consider, they should be applied based on individual patient needs using professional judgment, according to the National Guideline Clearinghouse. The clearinghouse is operated by the U.S. Department of Health and Human Services, Agency for Health Care Policy and Research (AHCPR) in partnership with the American Medical Association (AMA) and the American Association of Health Plans (AAHP).

Minimum criteria for guidelines are set by these organizations and published in the Federal Register.

Whether it is now practice or not to follow clinical practice guidelines depends in part on who issues the guidelines. If it's the college or board that certifies a specialty, that could create a standard of care against which doctors are measured or held liable," said Peters.

The study--Michael Cabana et al., Why Don't Physicians Follow Clinical Practice Guidelines? JAMA, Oct. 20,1999--is available at http://jama.ama-assn.org/issues/ v282n15/full/jrv90041.html.