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Attitudes of Israeli Family Physicians Toward Clinical Guidelines
Shlomo Vinker, MD;
Sasson Nakar, MD;
Elliot Rosenberg, MD;
Tal Bero-Aloni;
Eliezer Kitai, MD
Arch Fam Med. 2000;9:835-840.
ABSTRACT
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Background Many clinical guidelines (CGs) have been written during the past few years. Although family physicians (FPs) stand to benefit from many of these CGs, incorporating new CGs into daily practice seems to present a challenge.
Objective To evaluate Israeli FPs' attitudes toward CGs.
Methods We administered an anonymous questionnaire to general practitioners, residents, and board-certified FPs who participated in continuing medical education programs throughout Israel during May and June 1998. Our survey focused on physician attitudes and behaviors regarding CGs in general, and to CGs for treating the patient with diabetes mellitus (DM) in particular. The CGs for patients with DM have recently been promoted in the context of primary care quality improvement programs. Respondents also provided demographic and professional data.
Results Of the 404 questionnaires distributed, 293 questionnaires were returned for a response rate of 83%. The average (±SD) age of respondents was 40.2 ± 7.0 years, with a mean (±SD) of 13.3 ± 8.0 years in practice. Overall, opinion regarding CGs was positive. About half of the respondents thought CGs improved patient compliance. Comparisons between the various physician groups highlighted several notable differences. Two thirds of the general practitioners believed CGs improved patient compliance, while this was true of only one third of the FPs (P<.001). Most FPs (62%) and senior residents (69%) felt CGs did not constrain their clinical freedom, while less than half of the general practitioners and junior residents felt this way (P = .045). Eighty-three percent of all respondents agreed that the CGs for the treatment of DM were able to be implemented, and 75% believed the CGs assisted them in the management of patients with DM. Whereas 39% expressed concern about being able to adapt generic CGs to individual patient needs, only 27% (P = .002) felt this way about the DM CGs. The vast majority (92%) were interested in understanding the scientific evidence supporting CGs as a prerequisite to adopting them. Most respondents preferred limiting CG length to a maximum of 5 pages.
Conclusions We found support among Israeli FPs for the use of CGs. Clinical guidelines seem to be used in the field, in particular those developed for treating DM. In light of our findings, attention should be focused on optimally tailoring new CGs to meet scientific standards and crafting them to suit the preferences of local FPs.
INTRODUCTION
MEDICINE IS in the midst of a quality revolution. A major manifestation of this trend has been reflected in the adoption of evidence-based procedures.1 These procedures are increasingly communicated to the practicing physician in the form of clinical guidelines (CGs). More than 1000 CGs can be found in the Internet clearinghouse site of the Agency for Health Care and Policy Research.2 By standardizing the approach to well-defined clinical situations, they may eliminate unnecessary variance between medical practices, thus preventing errors of omission and commission.3 This characteristic allows the profession to set benchmarks, against which medical care can be compared.4 Clinical guidelines also serve to contain the cost of care for insurers and health care organizations.5
Many CGs have been written in Israel during the past few years. Most of the CGs in Israel have been developed by steering committees appointed by the health maintainance organizations (HMOs) or by the medical specialty societies operating within the framework of the Israeli Medical Association. As family physicians (FPs) deal with a wide spectrum of clinical cases, they stand to be both exposed to and, hopefully, benefit from many of the existing CGs. Whether this benefit, indeed, accrues will, to a large extent, depend on how FPs perceive these recent additions to the quality movement's options.
Several studies have assessed the attitudes of FPs regarding CGs.6-16 Wolff et al6 found that despite having generally positive attitudes toward CGs, FPs in the United States did not use CGs frequently in daily practice. Incorporating new CGs into daily practice seems to present a challenge for physicians. James et al10 noted that only 28% (119/419) of the physicians they surveyed reported adopting a new CG in the previous 12 months.
Lawler and Viviani17 assessed physician compliance with the patient follow-up component of a CG for diabetes mellitus (DM) care. In their study, glycosylated hemoglobulin was checked during the previous year in only 50% of the patients. This was despite the fact that 75% of the physicians claimed to have performed the test. Poor physician adherence characterized the CG for the periodic health examinations,18 as well as that for asthma therapy.19
It seems as if despite the relative support for CGs expressed by physicians, there exist barriers that prevent translation of that support into action at the clinic level. To progress toward effective CG implementation, we need to explore the nature and extent of these barriers and identify strategies to overcome them. One means of achieving this goal is to ask physicians regarding critical unmet needs and their expectations from workable CGs. This information should serve to inform effective CG development, and, ultimately, increase physician adherence to the CGs. To this end, we endeavored to survey a broad spectrum of Israeli primary care practitioners to elicit their attitudes and behaviors toward existing CGs, and to ascertain their preferences for the optimal design of future CGs.
PARTICIPANTS, MATERIALS AND METHODS
We administered throughout May and June 1998 an anonymous questionnaire to a convenience sample of physicians participating in continuing medical education (CME) programs affiliated with all academic departments of family medicine throughout Israel. All participating physicians were actively providing direct patient care during the survey period.
Three main groups of Israeli FPs take part in CME courses. The first group consists of board-certified FPs (also referred to as "specialists" in this article). They tend to be younger than the other groups taking CME courses. A substantial proportion of all Israeli FPs participate in the CME courses. Those in the second group (also referred to as general practitioners in this article) are older and more experienced. They are not board certified in family practice, as they typically began practicing medicine before the residency program came into existence. The third group consists of residents (junior and senior level) in family medicine. They are required to participate in CME courses as part of their training. Our survey focused on physician attitudes regarding CGs that have been written and disseminated in Israel for use by FPs.
The questionnaire was developed from an existing American family physician survey, with the authors' permission.6 It is available from us on request. The 28 study questions are divided into 2 sections.
Section 1 consists of 23 questions concerning physicians' general opinion of and perceived effectiveness of CGs, the extent to which CGs are used in everyday practice, and personal preferences regarding the source and format of the CGs. Additional questions dealt with the role CGs are thought to play in the field of medical malpractice. The physicians were also asked to cite titles of CGs that had been written or adopted in Israel in recent years.
Section 2 contained 5 questions concerning physician attitudes about the CG for treating the patient with DM. Clinical guidelines covering this area have been published by the 2 largest health maintenance organizations (HMOs) in Israel. Implementation of these CGs has recently been the focus of quality improvement programs. We did not distribute the CG to the participants as we assumed most of the physicians were familiar with it. Respondents also provided demographic and professional information such as age, sex, years in practice, professional status, and current teaching or administrative activities.
We distributed the survey to all participants in CME courses and collected them during the same session to maximize respondent compliance. A total of 404 questionnaires were distributed; 293 were returned for a response rate of 83%. The survey responses were entered in the Excel for Windows database and analyzed using SPSS for Windows (SPSS, Chicago, Ill). Data from open questions were reviewed by two of us (S.V. and T.B.-A.) and coded. We used descriptive statistics to analyze the responses to each item. Further statistical analysis was conducted to determine the existence of associations between respondents' demographic and professional characteristics and their attitudes toward CGs.  2 Testing was used for categorical variables, and analysis of variance was chosen to analyze continuous variables.
RESULTS
Two hundred ninety-three questionnaires were returned for a response rate of 83%. The average (±SD) age of the respondents was 40.2 ± 7.0 years, with a mean (±SD) of 13.3 ± 8.0 years in practice (Table 1). Most (55%) of the respondents were women. This corresponds with the preponderance of female physicians among Israeli FPs. A minority (9.2%) worked in solo practice. Approximately one quarter (23%) were involved in teaching family medicine, and about one fifth (20.5%) had an administrative component to their positions. Most of the latter were board-certified FPs.
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Table 1. Association Between Professional Status and Age and Experience Level of Physicians*
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Table 2 lists physicians' attitudes toward CGs in general. Responses have been grouped into the following 5 headings: overall opinion of CGs, belief in the effectiveness of CGs, physician reservations about CGs, practical value of CGs, and personal use of CGs. We also tested the participants familiarity with a specific CG—The Management of the Diabetic Patient.
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Table 2. Family Physicians' Attitudes About Clinical Guidelines (CGs)*
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OVERALL OPINION OF CGs
Responses were basically positive. No notable differences were evident among the different groups of physicians for any of the questions under this subcategory.
BELIEF IN THE EFFECTIVENESS OF CGs
Only about half of the respondents thought CGs improved patient compliance. This figure decreased to only one third when the responses of FPs were analyzed separately. However, a significantly greater percentage of general practitioners (two thirds) believed CGs improved patient compliance (P<.001).
PHYSICIAN RESERVATIONS ABOUT CGs
Most board-certified FPs and senior residents believed CGs did not constrain their clinical freedom. Significantly less uncertified GPs and junior residents (less than half of each group) felt this way (P = .045).
PRACTICAL VALUE OF CGs
A significantly (P<.01) higher percentage of residents, as opposed to both FPs and general practitioners, believed CGs helped them in daily practice. Physicians also differed (P<.001) by professional status for the question of CGs suitability for the individual patient. Family practitioners and senior residents were most optimistic on this count.
PERSONAL USE OF CGs
Family practitioners and senior residents were significantly more likely (P = .04) than others to avail themselves of CGs.
FAMILIARITY WITH SPECIFIC CGs
Table 3 rates existing Israeli CGs on the basis of their familiarity to the survey respondents. The hypertension CG was by far the best known.
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Table 3. Recognition of a Specific Treatment-Oriented Clinical Guideline
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ATTITUDE TOWARD A SPECIFIC CG— THE MANAGEMENT OF THE DIABETIC PATIENT
The respondents were quite supportive of this CG. Eighty-three percent agreed that the CG was able to be implemented, and 75% believed the CG assisted them in the management of patients with DM. Whereas 39% had expressed concern about being able to adapt a generic CG to individual patient needs, only 27% (P = .002) felt this way about this specific CG. Only 13% believed that use of the DM CG unnecessarily extended and encumbered the physician-patient encounter. In the same vein, only 30% thought that cost considerations were the impetus for the DM CG, whereas 74% asserted this was true of generic CGs.
LEGAL ISSUES
Most (68%) of the respondents asserted that use of CGs had the potential to protect physicians against malpractice suits. Conversely, only 23% believed the use of CGs increased the chance of malpractice liability for physicians.
CG FORMAT AND ORIGIN
Most survey respondents preferred limiting CG length to a maximum of 5 pages. Ninety-two percent predicated using CGs on being presented the scientific evidence base of the CG. Two thirds believed the authors should be named. Most physicians (77%) wanted to know details about the funding base of any guideline they would use.
An interesting professional dichotomy was evident for the preferred source of CGs. Fifty-nine percent of the respondents preferred they originate from the Israeli Medical Association, while 41% would rather these come from the HMOs. Most of the Israeli Medical Association proponents came from the ranks of board-certified, junior, and senior resident FPs (66%, 69%, and 72%, respectively). However, most (59%) of the uncertified physicians preferred the HMOs (P<.001).
COMMENT
Family practitioners in Israel generally support the use of CGs. This is manifest in both the extent to which they stated using them, as well as in the high prevalence of CGs in the clinics of our survey respondents. Results of studies from other Western countries9, 12-16 reflect a similar positive orientation of physicians regarding CGs.
Wolff et al6 found less support for CGs among the 205 American FPs they surveyed. These differences were manifest throughout the survey: Only 60% belived CGs were a positive development in medicine, as opposed to 90% among our study respondents. A minority of US physicians (33%) believed CGs would lessen the physician workload, whereas 84% of our respondents believed this to be the case. Finally, the difference in attitudes can be seen in daily practice. Among our Israeli cohort, 82% stated using CGs in daily practice, and 77% claimed they influence patient care. However, most of the US respondents did not use CGs, and only 34% believed they influenced patient care. All our respondents practice within staff model HMOs, whereas HMO physicians compose a minority of the survey respondents in the US studies quoted. There is evidence of a correlation between support for CG use and affiliation with staff model HMOs.20 This may reflect a less independent mentality on the part of these physicians.
Inouye et al11 followed up a cohort of physicians over 2 years to assess changes in their attitudes toward a preventive CG. Over time, support for the notion that CGs are used to control costs rose from 71% to 92%, while the percentage of those who believed CGs were primarily created to improve the quality of care decreased. As we have observed strong support among our cohort for the notion that CGs serve to control costs, it should be informative to follow them over time to detect any such trends.
This study not only assessed physician attitudes toward CGs in general, but also looked at physician attitudes toward a specific CG written for the treatment of DM. Much effort has been invested in disseminating this CG. Judging by our results, it would seem as if this effort has been successful. Seventy-five percent of the respondents reported using this CG. In addition, although most respondents were of the opinion that cost-cutting concerns were drivers of CG development in general, fewer than half this number (25%) felt this way about the DM CG. The trend toward greater agreement among physicians for specific vs theoretical and/or generic guidelines has been documented in a recent extensive literature review by Cabana et al21 regarding barriers to physician adherence to CGs.
With respect to a specific CG, the CG for the treatment of hypertension was by far the best known among the 7 CGs mentioned in the survey. This may stem from the high prevalence of hypertension, as well as from the emphasis the HMOs placed on the recommendations in this CG owing to its cost-cutting nature.
Various studies6, 8-9,22 have noted a positive bias toward CGs among new physicians as opposed to those with more experience. In general, we did not detect a clear training level–related trend. This may be due to a greater receptivity among our respondents to new initiatives, such as CGs, as it was conducted among physicians attending CME courses and all of them currently in practice, in contrast to those surveys sent to the physicians at their homes or clinics.6, 10 We assume that the younger physicians will more likely maintain their positive attitude toward CGs during their careers. However, it is possible that their attitudes will change as they gain experience and confidence, thus feeling less of a need for prescriptive practice guidelines. This important question awaits further longitudinal study. Despite these positive attitudes, there remain significant concerns regarding CGs among Israeli FPs. Nearly half believed CGs constrained their clinical freedom. This was especially evident among general practitioners's and junior residents, and may reflect a training effect.
A fair number (40%) believe CGs are too restrictive and difficult to adapt to individual patients. In a study by Tunis et al,22 24% of respondents believed CGs to be overly restrictive. Twenty-one percent saw them as a threat to physician autonomy. Similar concerns were expressed in a 1995 study from the United Kingdom,12 where more than 25% of respondents felt CGs cramped clinician decision-making latitude.
This cautious attitude is reflected in a 1997 survey of US family physicians.10 In this study, only 28% of respondents reported adopting a CG during the previous year. Survey respondents in the study by Wolff et al6 expressed similar sentiments. They stressed the need to temper the use of CGs with sound clinical judgment to cope with the variety, uniqueness, and uncertainty inherent in the physician-patient encounter. All the aforementioned studies may be summarized as demonstrating a qualified willingness among FPs to accept CGs as nonbinding recommendations.
Physicians in our study expressed a strong interest in CGs to be "transparent and explicit." This is in line with state-of-the-art "guidelines for writing guidelines."23 However, providing all this information may run counter to stated respondent preference for shorter CGs.
Most physicians preferred that the CGs be formulated by the Israeli Medical Association, an organization that represents most Israeli physicians. This trend is similar to that seen outside of Israel,5, 8 where physicians expressed greater confidence in CGs issued by their respective professional organization. It may be that HMOs are somewhat suspect, as they are thought to be motivated by financial, as well as by medical quality considerations.
The ultimate benefits of CGs are still controversial.24 Clinical guidelines have the potential to prevent provision of inappropriate care, to help protect physicians from malpractice suits, and to minimize the squandering of precious medical resources. However, they tend to oversimplify clinical care. There are even those who believe that CGs are overrated because they do not allow the clinician to cope with the diversity and complexity present in primary care.25 The challenge before every FP can thus be stated as knowing how to selectively integrate scientifically sound CGs into everyday practice without resorting to blind adherence to these, as yet, incomplete clinical tools.
Our study population consisted of both younger FPs and more veteran physicians (general practitioners). Both were recruited during their participation in a CME course in family medicine. The younger FPs participated in the course as part of the requirements of their residency program. The veteran physicians (general practitioners) came voluntarily for CME. As such, the attitudes of the veteran physicians may not necessarily reflect those choosing not to attend CME courses. Our respondents are representative of the decision-making strata of the specialty of family medicine. These younger FPs will lead the profession in the years to come. Thus, our respondents do constitute a meaningful segment of Israeli FPs.
CONCLUSIONS
We found support among Israeli FPs for the use of CGs. Clinical guidelines seem to be used in the field, especially those developed for treating DM. To optimize implementation and adherence to CGs, attention should be focused on tailoring new CGs to meet international scientific standards, as well as to suit the preferences and expectations of local family physicians.
AUTHOR INFORMATION
Accepted for publication June 25, 2000.
We thank Marie Wolff, PhD, of the Department of Family and Community Medicine at the Medical College of Wisconsin, Milwaukee, for providing us with her Practice Guideline Survey Tool. This was modified and translated into Hebrew to form the basis of the survey tool used in our study.
Corresponding author: Shlomo Vinker, MD, PO Box 14238, Ashdod 77042, Israel (e-mail: vinker{at}internet-zahav.net).
From the Department of Family Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Vinker, Nakar, Bero-Aloni, and Kitai); and the Department of Health Promotion and Disease Prevention, Ben-Gurion University, Negev, Israel (Dr Rosenberg).
REFERENCES
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1. Institute of Medicine. Clinical Practice Guidelines: Directions for a New Program. Washington, DC: National Academy Press; 1990.
2. National Guideline Clearinghouse Available at: http://www.guideline.gov. Accessed January 10, 2000.
3. Tierney WM, Overhage JM, Takesue BY, et al. Computerizing guidelines to improve care and patient outcomes: the example of heart failure. J Am Med Inform Assoc. 1995;2:316-322.
FREE FULL TEXT
4. McLaughlin CP, Kaluzny AD. Defining total quality management/continuous quality improvement. In: McLaughlin CP, Kaluzny AD, eds. Continuous Quality Improvement in Health Care: Theory, Implementation, and Applications. Gaithersburg, Md: Aspen Publishers Inc; 1994:3-10.
5. Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluation. Lancet. 1993;342:1317-1322.
FULL TEXT
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ISI
| PUBMED
6. Wolff M, Bower DJ, Marbella AN, Casanova JE. US family physicians' experiences with practice guidelines. Fam Med. 1998;30:117-121.
PUBMED
7. Langley C, Faulkner A, Watkins C, Gray S, Harvey I. Use of guidelines in primary care—practitioners' perspectives. Fam Pract. 1998;15:105-111.
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8. Helwig A, Bower D, Wolff M, Guse C. Residents find clinical practice guidelines valuable as educational and clinical tools. Fam Med. 1998;30:431-435.
PUBMED
9. Ferrier BM, Woodward CA, Cohen M, Williams AP. Clinical practice guidelines: new-to-practice family physicians' attitudes. Can Fam Physician. 1996;42:463-468.
ISI
| PUBMED
10. James PA, Cowan TM, Graham RB, Majeroni BA. Family physicians' attitudes about and use of clinical practice guidelines. J Fam Pract. 1997;45:341-347.
ISI
| PUBMED
11. Inouye J, Kristopatis R, Stone E, Pelter M, Sandhu M, Weingarten S. Physicians' changing attitudes toward guidelines. J Gen Intern Med. 1998;13:324-326.
FULL TEXT
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ISI
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12. Siriwardena AN. Clinical guidelines in primary care: a survey of general practitioners' attitudes and behaviour. Br J Gen Pract. 1995;45:643-647.
ISI
| PUBMED
13. Newton J, Knight D, Woolhead G. General practitioners and clinical guidelines: a survey of knowledge, use, and beliefs. Br J Gen Pract. 1996;46:513-517.
ISI
| PUBMED
14. Gupta L, Ward JE, Hayward RS. Clinical practice guidelines in general practice: a national survey of recall, attitudes and impact. Med J Aust. 1997;166:69-72.
ISI
| PUBMED
15. Grilli R, Penna A, Zola P, Liberati A. Physicians' view of practice guidelines: a survey of Italian physicians. Soc Sci Med. 1996;43:1283-1287.
16. Olesen F, Lauritzen T. Do general practitioners want guidelines? attitudes toward a county-based and a national college-based approach. Scand J Prim Health Care. 1997;15:141-145.
ISI
| PUBMED
17. Lawler FH, Viviani N. Patient and physician perspectives regarding treatment of diabetes: compliance with practice guidelines. J Fam Pract. 1997;44:369-373.
ISI
| PUBMED
18. Romman FJ, Fletcher SW, Hulka BS. The periodic health examination: comparison of recommendation and internists' performance. South Med J. 1981;74:265-271.
ISI
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19. Lang DM, Sherman MS, Polansky M. Guidelines and realities of asthma management: the Philadelphia story. Arch Intern Med. 1997;157:1193-1200.
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20. Shye D, Betz-Brown J. Primary care HMO clinicians opinions about clinical practice guidelines. HMO Pract. 1995;9:111-115.
PUBMED
21. Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines: a framework for improvement. JAMA. 1999;282:1458-1465.
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22. Tunis SR, Hayward RSA, Wilson MC, et al. Internists' attitudes about clinical practice guidelines. Ann Intern Med. 1994;120:956-963.
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23. Shaneyfelt TM, Mayo-Smith MF, Rothwangl J. Are guidelines following guidelines? the methodological quality of clinical practice guidelines in the peer-reviewed medical literature. JAMA. 1999;281:1900-1905.
FREE FULL TEXT
24. Kassirer JK. The quality of care and the quality of measuring it. N Engl J Med. 1993;329:1263-1265.
FREE FULL TEXT
25. Geyman JP. Clinical guidelines and primary care. J Am Board Fam Pract. 1992;5:656-657.
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