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Clinical Practice Guidelines on Depression
Awareness, Attitudes, and Content Knowledge Among Family Physicians in New York
Edward L. Feldman, MA, MSW;
Arnold Jaffe, PhD;
Nora Galambos, MS;
Anne Robbins, MB, ChB;
Robert B. Kelly, MD, MS;
Jack Froom, MD
Arch Fam Med. 1998;7:58-62.
ABSTRACT
Background In 1989, the federal government mandated that the Agency for Health Care Policy and Research (AHCPR) appoint expert panels to develop clinical practice guidelines to define standards for the provision and quality of health care. There is uncertainty about physicians' awareness and attitudes concerning guidelines.
Methods We surveyed 992 members of the New York State Academy of Family Physicians. In addition to demographic data, respondents were questioned about awareness of AHCPR guidelines for depression in primary care, urinary incontinence, and pressure ulcers in adults; knowledge of the diagnosis and treatment of depression; and general attitudes about guidelines.
Results Three mailings produced a response rate of 53.2%. While 90.5% of respondents treat depression in their primary care practices, only 33.6% are aware of the existence of the guidelines on depression 1 year after publication. Only 13.1% of respondents have a copy of the guidelines. Physicians are slightly less aware of the guidelines on urinary incontinence and pressure ulcers (30.0%). Respondents are generally knowledgeable about the diagnosis and treatment of depression, and board certification is correlated with increased knowledge about the treatment of recurrent depression. Logistic regression analyses demonstrate that female family physicians, those living in larger communities, and physicians with 3 or more years of training are most likely to have positive attitudes toward guidelines.
Conclusions The AHCPR guidelines failed to reach their targeted audience. Specific strategies derived from survey data can identify physicians who may most benefit from educational interventions.
INTRODUCTION
CLINICAL practice guidelines have proliferated in the last several years for several reasons. Regional variations in medical practices, not supported by scientific evidence, can result in increased health care costs and suboptimal outcomes.1-5 Based on extensive reviews of the literature, guidelines are an attempt to educate physicians concerning evidence-based medical care. Through the use of expert panels, guidelines seek to improve the current standards of care and outcomes of medical interventions nationwide. Guidelines may reduce health care costs by decreasing unnecessary services but may increase expenditures by increasing use of services.6-7
Several professional organizations have developed clinical practice guidelines. These include specialty and subspecialty boards,4 the National Institutes of Health,4 the American Medical Association,4 the US Preventive Services Task Force,8 Blue Cross/Blue Shield,9 and the Agency for Health Care Policy and Research (AHCPR) established by the federal government in 1989. One mandated mission of the AHCPR is the establishment of expert panels to develop guidelines on a variety of medical topics. These have included sickle cell disease,10 pressure ulcers in adults,11 urinary incontinence,12 cataracts,13 benign prostatic hypertrophy,14 pain,15 otitis media with effusion,16 evaluation and management of early human immunodeficiency virus infection,17 quality determinants of mammography,18 and depression in primary care.19-21
A clinical guideline designed to improve quality of care can be useful only if physicians are aware that it has been developed,5 if they have reviewed and accepted its contents,22 and if they have a positive and receptive attitude toward guidelines.4, 23 Effective dissemination is essential to implementing guidelines.24 There is limited research evaluating the effectiveness of dissemination, with 1 study finding only moderate success at reaching a portion of the targeted group.25 To examine the success of dissemination of a national guideline designed specifically for primary care physicians, we surveyed family physicians in New York on their attitudes toward and awareness and knowledge of the content of the AHCPR clinical practice guideline on depression in primary care.19-21 This guideline was chosen because, in contrast to others, its target audience is primary care physicians, and it was released about 1 year before our survey. We did not include in our survey a version of the depression guidelines designed for use by patients.26
MATERIALS AND METHODS
INSTRUMENT
We developed a survey instrument to assess the attitudes toward and awareness and knowledge of the content of the AHCPR clinical practice guidelines on depression in primary care. It contained questions about physicians' demographic, educational, and practice characteristics and their general attitudes toward guidelines. The initial survey instrument was pretested among 15 physician faculty and 50 graduates of the residency program at the State University of New York at Stony Brook. To maximize physician response, the final 4-page survey included only those items that performed well on the pretest and permitted a completion time of less than 10 minutes. Individual items included age, sex, race, board certification, years of residency training, size of practice community, type of practice, and whether respondents taught medical students, practiced with a mental health practitioner, and usually treated depression without a referral to a psychiatrist. There were questions concerning if and how respondents became aware of the AHCPR's guidelines on depression in primary care and urinary incontinence and pressure ulcers in adults, and if they had a copy of the depression guidelines. Knowledge of the content of the guidelines and general attitudes toward guidelines were assessed by questions about the extent to which they agreed with a series of content and attitudinal statements on a 6-point scale, ranging from "strongly disagree" to "strongly agree."
PHYSICIAN SAMPLE
A random sample of 992 of the 1752 members of the New York State Academy of Family Physicians was selected to receive the survey, which was coded so that only nonrespondents would receive subsequent mailings. The sample size was chosen to protect against the possibility of low response rate. If the response rate had been as low as 30%, a power of greater than 0.80 on a 5x5 table with a moderate effect size of 0.30 for  =.01 would have been guaranteed.27 Uniform random numbers were generated to select about 57% of the members, resulting in a sample of 992 addressees.
PROCEDURE
The initial survey was mailed March 30, 1994, with a letter of support from the president of the Research and Education Foundation of the New York State Academy of Family Physicians and included a postage-paid return envelope. A second mailing was sent to nonrespondents 3 months later, and a third and final mailing was sent to nonrespondents September 4, 1994. To ensure anonymity, addressees were assigned a preprinted coded number that remained the same throughout the 3 mailings.
ANALYSIS
In analyzing the data, the tables were collapsed to raise the minimum expected value in the contingency tables. The 6-point scale used for all questions was collapsed to a 2-point scale (1-3 indicate low levels of agreement; 4-6, high levels) to provide sufficient data in each cell for analysis. Measured continuously, respondent ages were divided as younger than 36 years, 36 to 50 years, and older than 50 years. Years of family practice residency were divided as none, 1 to 2 years, and 3 years or greater. The  2 statistics and logistic regression analyses were used to examine significant relationships among the variables.
RESULTS
From the total sample of 992 physicians, 14 surveys were returned without forwarding addresses, 2 surveys were ineligible because the respondents were retired, and 1 respondent was no longer in the Academy, resulting in an effective sample size of 975 physicians. The first mailing resulted in 291 valid responses (29.3%), the second mailing yielded 152 responses (15.3%), and the third mailing yielded 76 responses (7.7%), for a total of 519 responses (53.2%) for statistical analysis. The 519 respondents were not significantly different in age and sex from the population of members of the New York State Academy of Family Physicians.
DEMOGRAPHIC CHARACTERISTICS
The distribution of respondents' characteristics appears in Table 1. Most respondents were young (<45 years), white, male, and board certified and had 3 or more years of family practice residency training. Almost half practiced in communities of less than 50000 people and more than half taught medical students or residents.
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Table 1. Demographic Characteristics of Sample*
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AWARENESS
Only 33.6% of respondents were aware of the existence of the AHCPR guidelines on depression in primary care. Of those who had heard of the guidelines, 40.0% (13.1% of the total sample) actually had a copy of the guidelines. Respondents were less aware of the AHCPR guidelines on urinary incontinence and pressure ulcers in adults (30.0%). Respondents who were aware of the guidelines were more likely to treat depression (P=.01) and believed they had more knowledge about the diagnosis and treatment of depression (P=.04). Those who had a copy of the guidelines found treating depression slightly more rewarding than those who did not (P=.05).
TREATMENT
Among our respondents, 90.5% treated depression independently, and 30.9% practiced with a mental heath practitioner (psychiatrist, social worker, or psychologist). Although the latter percentage is higher than expected, more than two thirds of our sample worked in settings other than solo practices.
Age, amount of residency training, and size of the community in which the respondent practiced were significantly associated with treatment responses. Young physicians (<36 years) were most likely to treat depression (P=.03), and physicians younger than 50 years believed that they were well trained to do so (P=.001). A stepwise logistic regression analysis showed that characteristics associated with treating depression frequently were teaching medical students (P<.001) and 3 or more years of residency in family practice (P=.007). Physicians practicing in larger communities (>400000 population) were less likely to treat depression (P<.001) (Table 2).
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Table 2. Predictors of Treatment of Depression
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KNOWLEDGE
Respondents were generally knowledgeable about the diagnosis and treatment of depression as measured by responses to questions derived from the guidelines. Board-certified family physicians were more knowledgeable about the treatment of recurrent depression (P=.04) than were those not certified, but were less likely to view psychotherapy as being as effective as drugs in the treatment of mild to moderate depression (P=.04).
ATTITUDES
General attitudes toward guidelines were mixed, as demonstrated in Table 3. Whereas physicians believed that guidelines had value for teaching and patient care, they had concerns about their legal consequences. This ambivalence is highlighted by the fact that whereas 65.3% agreed that "guidelines are a tool of the legal profession," 92.9% believed that they had "value in teaching," and 42.5% of those who did not have a copy of the guidelines on depression requested that a copy be sent to them. A stepwise logistic regression analysis of outcome variables that predicted attitudes toward guidelines found that female physician and those practicing in larger communities (>50000 population) are most likely to think that guidelines are important, compared with those practicing in smaller communities (<10000 population) (Table 4).
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Table 3. General Attitudes Toward Guidelines
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Table 4. Predictors of Positive Attitudes Toward Importance of Guidelines
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COMMENT
Benefits of clinical practice guidelines include a systematic review of the literature by a panel of experts and specific clinical advice supported by research. Since the purposes of some guidelines are cost containment and facilitation of peer review, physicians may perceive them as a threat to autonomy and an attempt to force a "cookbook" approach to clinical decision making.28 These negative effects may be felt by family physicians in particular, whose domain includes many of the 1500 published guidelines.29
Reports on the effects of guidelines on practice are mixed. Grimshaw and Russell3 report that physicians who were informed about the content of guidelines changed their practices in the manner suggested by the guidelines in 55 of the 59 studies they reviewed. Other studies report that guidelines often do not affect clinical practice or medical outcomes.4, 25, 30-32
The clinical practice guideline on depression in primary care was chosen for our survey because depression is a common syndrome in primary care patients, and because most patients have an existing relationship with a primary care physician. The guidelines were published in the spring of 1993. The AHCPR's dissemination strategy included news articles appearing in about 70 newspapers throughout the United States (including the New York Times, Wall Street Journal, Washington Post, and USA Today ). There were more than 75 national presentations on television, including CNN, ABC, and NBC nightly news programs and at least 60 radio reports.33 In addition to national coverage, regional presentations particularly relevant to this sample of physicians included Newsday (Long Island, NY), The Observer-Dispatch (Utica, NY), and The Times-Union (Albany, NY).33
The published guidelines were made available to physicians at no cost by calling a toll-free number, and a summary of the content was published in several family medicine and general interest journals, including American Family Physician,34 JAMA35, Journal of the American Board of Family Practice,36 Family Practice News,37 Archives of General Psychiatry,5 Patient Care,38-39 and Journal of the National Medical Association40.
In spite of this extensive dissemination program, our survey demonstrated that family physicians in New York were generally unaware of a guideline specifically targeted to them. A full year after publication, only 33.6% of our sample had ever heard of these guidelines, and only 13.1% actually had a copy of the guidelines. Physicians in our sample were generally knowledgeable about the diagnosis and treatment of depression as determined by answers to content questions derived from the guidelines. Respondents had ambivalent attitudes toward guidelines in general.
Generalizability of these results may be questioned if New York family physicians are not representative of others in the United States, but there are no data that suggest differences between these groups. This sample of respondents who were younger than 45 years, male, white, and board certified and had 3 years of family practice training may not represent the population of family physicians. Another limitation of our study is our inability to extensively measure physicians' knowledge of the content of the guidelines. We tested the major constructs, but a longer instrument might have decreased our response rate significantly. Our response rate of 53.2% is considered acceptable in a large mail survey. Our results may include some selection bias, because about one third of our sample practiced with a mental heath practitioner, and family physicians with a particular interest in this topic may have responded to the survey.
Our findings are similar to those reported in a study of general practitioners in England, in which 69% of respondents believed that guidelines could improve patient care.41 A substantial minority (>25%) believed that guidelines could lead to cookbook medicine and reduce clinical freedom. In contrast to American physicians, those in Great Britain (64.8%) believed that following guidelines would reduce chances of a malpractice suit. Differences between countries may be explained by the widely divergent frequency of malpractice law suits.
CONCLUSIONS
Clinical practice guidelines can be an important component of family medicine education and practice and will likely grow in importance in the next decade. With the increasing development of managed care systems of health care provision, guidelines may become a means of allocating clinical reimbursement and measuring the standard of care. If guidelines are to educate physicians effectively, to influence their practices, and to improve the quality of patient care, physicians need to be aware of such guidelines in areas pertaining to their practices and to have a positive attitude about them.
The AHCPR's depression guidelines failed to reach their target audience, although the reasons for failure are uncertain; 84.7% of the physicians in our sample who had not heard of the guidelines requested a copy when completing the survey. The design of our study suggests several ways to improve promulgation of guidelines. Medical schools and hospitals can survey graduates of appropriate specialties to determine interest in and knowledge of the subject matter of the guidelines. The survey can identify attitudes and knowledge gaps in subgroups that may be susceptible to an educational intervention. For example, our data indicate that male family physicians practicing in small communities and who have less than 3 years of training were more likely to have negative attitudes toward guidelines, less likely to have heard of the guidelines on depression, and less likely to request them. The costs of such surveys are modest when compared with extensive use of media and advertising to disseminate information about guidelines. This method of reaching the targeted audience is likely to be a more efficient and effective use of resources. Other methods of making physicians aware of guidelines may include integrating them into computer-based patient care systems such as electronic medical records. Further research is needed to develop more effective methods of disseminating important evidence-based medical information for physicians.
AUTHOR INFORMATION
Accepted for publication November 13, 1996.
Supported in part by a grant from the Research and Education Foundation of the New York State Academy of Family Physicians.
We appreciate the efforts of Stephanie Nevin in preparing the instrument and collecting the data.
Reprints: Edward L. Feldman, MA, MSW, Department of Family Medicine, State University of New York at Stony Brook, Stony Brook, NY 11794-8461.
From the Departments of Family Medicine (Mr Feldman, Drs Jaffe, Robbins, and Froom) and Psychiatry and Behavioral Science (Ms Galambos), State University of New York at Stony Brook, and MetroHealth Campus, School of Medicine, Case Western Reserve University, Cleveland, Ohio (Dr Kelly).
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