Resistance to best-practice guidelines

What follows is excerpted from “The convergence of quality and efficiency,” by Helen Blumen and Lynn Nemiccolo.


Unfortunately, even when guidelines score well using the AGREE instrument, providers may still view them negatively. One example of this is an examination of guidelines conducted by researchers at RAND. One of the questions within the AGREE rigor-of-development domain requires that experts in both clinical content and guideline methodology who are external to the organization that has developed the guidelines review them, but it does not provide detailed specifications for the review. RAND researchers examined a set of guidelines for common, expensive diagnostic testing and treatment for musculoskeletal disorders of the spine and extremities. The researchers gave these guidelines high scores using the AGREE instrument. Then they asked a panel of providers (recommended by their specialty societies as leaders in their clinical field) to rate the relevance of the guidelines to common clinical situations and consistency with clinical understanding of existing evidence and expert opinion. The expert panelists thought that the guidelines did not address common clinical situations, and reported that they often disagreed with the experts’ interpretation of published evidence and clinical experience. In the face of findings of this nature, it is not surprising that guideline adherence in real-world situations may be imperfect, or that implementation of guidelines in healthcare systems may be met with resistance.


This can partly explain the low rate of adoption in the United States of clinical decision support (CDS) tools in the care of patients, even though they have been clearly established as a critical component in the delivery of the most up-to-date and effective care. CDS tools consist of physician order sets, electronic alerts, reference materials, reports related to patient data, and clinical guidelines. These tools provide access to current evidence-based clinical content, which will promote best practices at the point of care as well as allow for the evaluation of health outcomes.


In 2001, the Institute of Medicine made a strong case for the adoption of such tools with its publication Crossing the Quality Chasm: A New Health System for the 21st Century. One of the recommendations put forth in that publication was that the secretary of the U.S. Department of Health and Human Services be responsible for the establishment of a program for making evidence-based clinical information readily available. The program was to include the development of CDS tools that would aid the application of that evidence to all clinical practice. Though widely accepted, there has been a surprisingly low rate of adoption of such tools in actual clinical settings.


All of this brings us to the present push for electronic health records (EHR—a term that has come to encompass the digitizing of health information, including CDS, computerized physician order entry [CPOE], and a variety of other health information technology subsets). To date, EHR adoption rates by U.S. hospitals have been extremely variable. The federal government and the Robert Wood Johnson Foundation recently financed a survey of hospitals in an attempt to better understand variability in the use of the EHRs and CDS tools. The study aimed to help the government analyze the state of the healthcare industry as it plans for the future under the American Recovery and Reinvestment Act (ARRA). The results of that survey, which were recently published in the New England Journal of Medicine (NEJM), found that only 1.5% of the hospitals surveyed had comprehensive EHRs, while an additional 17% had basic EHRs, implemented at least partially. Forty-seven percent of the hospitals surveyed had no present plans to implement clinical decision support. The percentage was slightly lower for clinical decision support related to drug-to-drug interactions and abnormal lab value results. This low rate of adoption of support tools suggests the existence of major barriers to acceptance.


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