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Practice Guidelines: Useful and "Participative" Method?
Survey of Italian Physicians by Professional Setting
Giulio Formoso, MPH, MPharm;
Alessandro Liberati, MD;
Nicola Magrini, MD
Arch Intern Med. 2001;161:2037-2042.
ABSTRACT
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Background Professional setting might be a key determinant of physicians' attitudes
toward practice guidelines, influencing the effect of their implementation.
Because no previous surveys have specifically considered this aspect, we evaluated
the perceived role and usefulness of guidelines, as well as barriers to and
facilitators of their implementation, for hospital, primary care, and nonpracticing
clinicians.
Methods A 43-item self-administered questionnaire was sent to all National Health
Service physicians in the province of Modena, Italy (593 primary care physicians,
1049 hospital physicians, and 149 nonpracticing clinicians), and 1199 (66.9%)
responded. Opinions and attitudes were assessed using 5-point ordinal scales
and an attitude measurement scale. Results were evaluated overall and by professional
setting, sex, age, year of graduation, and academic background.
Results Practice guidelines were generally perceived to be less useful than
other sources of medical information (eg, personal experience, conferences,
colleagues, articles, the Internet, and textbooks [pharmaceutical representatives
were the exception]). Most physicians thought that guidelines are developed
for cost-containment reasons and expressed concerns about their limited applicability
to individual patients and local settings. Most respondents did not favor
the involvement of health professionals other than physicians in guideline
development and use and preferred nonmonetary incentives for their implementation.
Answers to individual items and attitude scores varied significantly across
professional settings. Primary care physicians showed, in general, the least
favorable attitudes toward practice guidelines, toward nonphysicians participating
in guideline development and use, and toward incentives for guideline users.
Conclusions Physicians perceived practice guidelines as externally imposed and cost-containment
tools rather than as decision-supporting tools. Regularly monitoring attitudes
toward practice guidelines can be helpful to evaluate potential barriers to
their adoption.
INTRODUCTION
EFFORTS TO improve quality and appropriateness of care based on practice
guidelines have been implemented in various countries and have produced inconsistent
effects on physicians' behavior, ranging from success to failure.1-3 Physicians' attitudes
toward guidelines4-5 and the way
they are implemented3, 6-7
can help explain these results more than their methodological quality,8-9 which is often poor, as has been suggested
recently, especially for guidelines developed by scientific societies.10 A nationwide practice guidelines program has been
launched recently in Italy with the goal of supporting the effectiveness,
appropriateness, and equity of health care interventions.11
This program could play a central role in guideline development and in local
actions for implementation.
Overall, results of available studies indicate that physicians still
do not perceive guidelines as supporting tools for their work, suspecting
that they could be used as cost-containment tools.12-14
Moreover, physicians seem to resist the idea that guideline development should
be multidisciplinary,15 which is now the preferred
method for developing valid and reproducible evidence-based guidelines. Whether
this indicates a defensive reaction or the expected time lag for a complex
cultural shift to take over, these attitudes represent important barriers
to guideline implementation.7 Exploring and
understanding these barriers might increase the acceptance and use of practice
guidelines and the likelihood of producing the expected changes.
We surveyed 1791 National Health Service physicians working in the province
of Modena in northern Italy (615 000 inhabitants), where a center (the
Centre for the Evaluation of the Effectiveness of Health Care) involved in
the development and implementation of practice guidelines has recently been
established. In addition to investigating barriers, we explored the role of
cultural and economic incentives as possible "facilitators" and evaluated
whether professional setting can affect physicians' attitudes.
PARTICIPANTS AND METHODS
METHODS
We designed a self-administered questionnaire centered around 6 questions
(corresponding to 43 items) aimed at exploring physicians' opinions and attitudes
about practice guidelines. Opinions (defined as cognitive judgments) about
the following specific issues were investigated: relevance of guidelines compared
with other sources of clinical information; use of incentives linked to guideline
use; distribution of guidelines to groups other than health professionals;
participation of different health professionals in guideline development;
and usefulness of different guideline formats. Statements or items were answered
using 5-point ordinal scales (eg, 1 indicates "strongly disagree" or "completely
useless" and 5 indicates "strongly agree" or "very useful" depending on the
specific question). General attitudes were investigated using factor analysis
(by assessing physicians' evaluation of certain attributes pertaining to guidelines)
according to the definition of attitudes given by Fishbein and Ajzen16 (which highlights the emotional component of attitudes
vs the purely cognitive structure of opinions). Information about demographic
and professional characteristics of responders (age, sex, year of graduation,
and specialty) was also sought.
The questionnaire was mailed in June 1999 to 1791 National Health Service
physicians in Modena; 2 follow-up mailings were sent to nonresponders in July
and September 1999. The study population was comparable to the population
of Italian physicians working within the National Health System, the distribution
of these physicians being homogeneous across the various Italian provinces.
The general characteristics of survey responders and response rates are described
in Table 1.
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Table 1. Characteristics of Survey Responders
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DATA ANALYSIS
Responders were divided into subgroups according to sex, age (5 subgroups),
year of graduation (5 subgroups), professional setting (primary care [ie,
office practice], hospital, or nonclinical [preventive services or administration]),
academic background (medical, surgical, laboratory, or other), and timing
of response (first, second, or third mailing).
Factor analysis was performed using the 17 items designed to investigate
physicians' general attitudes about guidelines (evaluation of their usefulness,
reliability, and applicability); this analysis revealed 1 prevalent factor,
as expected (eigenvalue, 4.1). Items with more than 50% positive or negative
correlation with this factor (n = 9) were used to develop an attitude measurement
scale by summing ordinal scale ratings (items negatively correlated with the
factor were reversed); 2 items were left out because most responders agreed
with the corresponding statement (little discriminating power) and 7 items
were used (Table 2). The internal
consistency coefficient (Chronbach  ) for this scale was .82. The distribution
of the attitude score was skewed; differences among specific subgroups (sex,
age, year of graduation, professional setting, and academic background) were
investigated using analysis of variance with Bonferroni correction, verifying
equality of variances with the Bartlett test. Stepwise linear regression models
were then used to investigate whether answers to each of the 43 items depended
on physicians' general attitudes, perceived utility, sex, age, year of graduation,
professional setting, and academic background. Analysis of variance with Bonferroni
correction and the Bartlett test were also performed to explore differences
among subgroups. The 5-point Likert scales were eventually collapsed into
3 categories.
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Table 2. Opinions of Responders About Guidelines, Overall and by Professional
Setting
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RESULTS
The overall response rate was 66.9% (37.1%, 20.0%, and 9.8% after the
first, second, and last mailings, respectively). Professional setting was
the main factor that consistently and significantly explained differences
concerning attitude scores and all but 2 individual items. On the contrary,
attitude scores and answers to items did not differ by sex, age, year of graduation,
and time to answer. Marginally significant differences were found by academic
background, with physicians specialized in subjects pertaining to diagnosis
(ie, radiology, radiodiagnostics, laboratory medicine, microbiology, nuclear
medicine, clinical pathology, and medical genetics) having higher attitude
scores than those specialized in subjects pertaining to surgery or internal
medicine (P = .06).
GENERAL ATTITUDES AND PERCEIVED USEFULNESS OF GUIDELINES
The mean attitude score was 23.4 (theoretical range, 7-35; midpoint,
21), indicating that physicians generally had positive attitudes toward practice
guidelines. Nonpracticing clinicians had the highest score (mean, 26.7) and
primary care physicians had the lowest score (mean, 21.3); the score for hospital
physicians (mean, 24.3) was close to the overall mean value. The mean attitude
score of nonpracticing clinicians was significantly higher than that of primary
care and hospital physicians (P<.001 and P = .002, respectively); the hospital physicians' score
was significantly higher than that of their primary care colleagues (P<.001).
Practice guidelines were perceived as "useful in daily practice" by
85.7% of responders and were thought to represent a "reliable synthesis of
the available evidence" by 81.7% of responders. However, concerns were expressed
about their usefulness for individual patient care (60.7% of responders thought
that guidelines are generally too rigid to be applied to individual patients)
and their flexibility to local situations (58.7% thought that guidelines generally
do not consider local situations) (Table
2), somehow contradicting the previous results. Other sources of
information (personal experience, conferences, colleagues, articles, the Internet,
and textbooks), except pharmaceutical representatives, were thought to be
more useful than guidelines (Table 3).
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Table 3. Responders' Opinions About the Usefulness of Guidelines Compared
With Other Sources of Medical Information, Overall and by Professional Setting*
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ATTITUDES TOWARD A MULTIDISCIPLINARY APPROACH
Our study population did not seem to favor multidisciplinary participation
in guideline development and implementation. Less than half of the responders
had positive opinions about guidelines being distributed to health administrators
(only 47.2% agreed), patient groups (43.9%), and insurance companies (33.1%)
(Table 4). Moreover, administrators
and patient representatives were not particularly welcome as members of multidisciplinary
panels in guideline development (62.6% and 53.6% of responders did not think
the former and the latter, respectively, should be included on the panel),
and neither were nurses, communication experts, and even nonspecialist physicians
(Table 5). On the other hand,
in addition to practicing physicians (specialists and primary care physicians),
the presence of medicolegal experts was seen as favorable (81.1% agreed that
they should be on the panels), confirming that physicians have concerns about
legal risks17; the importance of epidemiologists-methodologists
was acknowledged too (Table 5).
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Table 4. Responders' Opinions About the Advisability of Distributing
Guidelines to Nonmedical Groups, Overall and by Professional Setting*
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Table 5. Responders' Opinions About Which Health Professionals Should
Participate in Guideline Development, Overall and by Professional Setting*
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A sharp difference emerged among professional subgroups: nonpracticing
clinicians were more and primary care physicians were less "multidisciplinary
oriented" than average (Table 4
and Table 5). After adjusting
for professional setting, general attitudes were still positively associated
with a multidisciplinary inclination; this confirms that a positive attitude
can be a crucial prerequisite for guideline implementation.
ATTITUDES TOWARD INCENTIVES
Direct economic incentives were not thought to be appropriate (only
36.9% of responders thought they are). On the contrary, nonmonetary incentives
(ie, journal subscriptions and participation in medical congresses) and structural
incentives for health services (eg, new equipment) were considered appropriate
(by 83.5% and 69.4% of responders, respectively) (Table 6). Nonpracticing clinicians were the most and primary care
physicians were the least "incentives oriented."
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Table 6. Responders' Opinions About Incentives Linked to Guideline
Use, Overall and by Professional Setting*
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PREFERRED FORMATS
Physicians regarded detailed (75.2%) and referenced (59.6%) formats
as more useful than short pamphlets with flowcharts only; 69.1% considered
electronic versions to be a good way of presenting guidelines. These results
might suggest that even if appreciating synthetic and "user friendly" versions,
physicians prefer to have access to the evidence base of guidelines (ie, reference
lists, systematic reviews, evidence tables, critical comments, etc).
COMMENT
The debate about the potential and the limitations of practice guidelines
has often been confounded by the suspicion that they could be used as cost-containment
tools. Progressively, however, guidelines have evolved into tools aimed at
supporting the effectiveness, appropriateness, and equity of health care interventions.
The methodology of guidelines has indeed contributed to highlighting 2 important
principles: (1) evidence-based decision making—scientific evidence systematically
gathered and critically appraised should be highly relevant when making health
care decisions, at the patient and policy level, and (2) participation and
balanced judgment—various stakeholders, ie, patients, physicians, and
administrators and other health professionals, can and should add a valuable
contribution to finalize these decisions.18
In the words of Lomas,19 practice guidelines
should become "the embodiment of the best available solutions" and probably
also "a step toward the increased democratization of medicine." However, attitudes
expressed in our survey did not seem to agree with these points.
USEFUL METHOD?
Physicians in our survey did not seem to regard guidelines as the "embodiment
of the best available solutions." Although there was general agreement on
the usefulness and reliability of practice guidelines, other traditional sources
of information still enjoyed more popularity (except pharmaceutical representatives).
The principles of evidence-based medicine still earned limited success, as
personal experience and opinions of specialist colleagues were regarded as
more useful and informative than guidelines. In general, the less time-consuming
and the more easily available the information source is, the more relevant
it was perceived, in keeping with what Smith20
conceptualized about physicians' information needs. Concerns about transferability
of guideline recommendations to individual patients and local situations,
in line with what has already emerged from Canadian21
and British22 surveys, might also help explain
those opinions. Moreover, a national guidelines program has been promoted
in Italy later than in other countries, and thus guidelines might be perceived
as rigid protocols and a "challenge to physicians' autonomy" rather than as
"systematically developed statements to assist practitioner and patient decisions
for specific clinical circumstances."23 In
this respect, guidelines seemed to end up being considered administrative
rather than educational and informative: most of our study population thought
that guidelines are developed for cutting costs. This is also consistent with
results of American, Canadian, and Australian surveys.12-14,21
"PARTICIPATIVE" METHOD?
With the partial exception of nonpracticing clinicians, our study population
did not seem eager to broaden their participation in guideline development
and use. Generally, physicians were not comfortable with the idea of nonphysicians
or specialists from different clinical areas participating in guideline development
(only medicolegal experts and methodologists' participation was considered
important), and they did not agree with practice guidelines being distributed
to nonmedical groups. A recent Italian survey,24
although suggesting that physician attitudes have evolved favorably during
the past few years, came to similar conclusions. Physicians still seem to
regard guidelines as "their own" reference tool, not as an opportunity for
discussion among all the stakeholders involved in the health care process,
to develop clinical policies and set priorities more in line with the available
evidence and with societal values.19 Health
care seems to be considered strictly a medical more than a societal problem,
and only physicians are entitled to have a say in it.
DIFFERENCES ACROSS PROFESSIONAL GROUPS
Attitudes toward guidelines and their attributes were variable in our
study population. Nonpracticing clinicians, ie, those not directly involved
at the bedside, showed the most favorable attitudes toward practice guidelines
in general, toward their usefulness, and, more broadly, toward a multidisciplinary
approach. Hospital clinicians and especially primary care physicians, on the
other hand, seemed to have more reservations about guidelines, their usefulness,
and the participation of nonphysicians in their development and use. Investigating
reasons for this variation can shed light on important issues about guideline
development and implementation. A first sensitive point is the physician-patient
relationship: practicing physicians differ from their nonpracticing colleagues
because they have to apply their decisions to individual patients. Hence,
they often have to negotiate their relationship with patients, weighing the
theoretical appropriateness of a decision with patients' values and expectations
and with risks of legal liability. As expected, practicing physicians were
generally less optimistic about the applicability of guidelines to individual
patients and about guidelines improving physician-patient relationships and
providing protection from medicolegal risks (Table 2). Primary care physicians in particular seemed to be the
least enthusiastic about guidelines. There might be economic reasons as well.
Italian primary care physicians are paid on a per capita basis; hence, they
are financially dependent on their patients and are probably more careful
about not "disappointing" them. Moreover, Italian primary care physicians
do not have fundholding status, a condition that has been shown to favor a
more positive attitude toward guidelines.25
Finally, working environments and organizational arrangements might also play
an important role: Grol26 suggests that physicians
working solo have less information and seem to change their practices and
habits less than practitioners who collaborate closely with each other; this
theory has been confirmed by a US survey of family physicians.27
This rationale partially applies to our study population: Italian primary
care physicians generally work independently, whereas nonpracticing clinicians
generally work in teams and follow some "rules"; the latter also have previously
been exposed to practice guidelines, and their attitudes might have had more
time to evolve favorably. That primary care physicians are less familiar with
guidelines is also suggested by their higher percentage of "no opinion" answers
than other groups in our survey.
STUDY LIMITATIONS
Because we used a mail survey, we cannot rule out that some form of
selection bias might have occurred. Although our response rate was fairly
high (66.9%), we have not performed an additional inquiry regarding nonresponder
characteristics to see whether they differed systematically in their attitude
toward guidelines. Moreover, the medical center promoting this survey is known
among responders as an institution committed to guideline promotion and implementation.
Therefore, we cannot rule out some form of "social convenience" or Hawthorne
effect bias in the answers. The relatively marked differences in the opinions
expressed across professional settings, however, suggests that this bias,
if present, did not substantially alter our results.
CONCLUSIONS
The results of our study suggest that despite the increasing popularity
of practice guidelines, traditional views of health care and medical information
are still deeply rooted in the medical profession. Physicians prefer other
sources of information, especially their own and their colleagues' experience,
to practice guidelines. Moreover, participation of nonphysicians in guideline
development and use (hence, in health care decisions) is not viewed enthusiastically.
Health care is a complex process involving different parties and different
alternatives and implying societal choices. Yet, physicians do not like external
interference in health care decisions and worry that these might threaten
their role or put them in a difficult position with their patients.
It might take time for the evidence-based and multidisciplinary "approach"
to be more widely accepted. Reducing this time lag seems to be an important
cultural priority that should start in medical schools, eg, by including guidelines
in teaching materials. For those who are physicians now, their involvement
in multidisciplinary groups can fulfill that approach while providing a "training
gym." Evidence-based practice centers and opinion leaders28
are crucial investments to favor an improvement of the cultural milieu, by
involving health professionals and helping them agree on, adapt, and implement
practice guidelines and evidence-based health policies. Within the implementation
process, monitoring attitudes would also help to understand, and eventually
overcome, potential barriers to the use of practice guidelines.
AUTHOR INFORMATION
Accepted for publication December 5, 2000.
Corresponding author and reprints: Giulio Formoso, MPH, MPharm, Centre
for the Evaluation of Effectiveness of Health Care, Viale Muratori 201, 41100
Modena, Italy (e-mail: g.formoso{at}ausl.mo.it).
From the Centre for the Evaluation of the Effectiveness of Health Care
(Drs Formoso, Liberati, and Magrini) and the Department of Hygienistic, Microbiologic,
and Biostatistic Sciences, Università di Modena e Reggio Emilia (Dr
Liberati), Modena, Italy.
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