Chest
Volume 118, Issue 2, Supplement, August 2000, Pages 8S-17S
Journal home page for Chest

Translating Guidelines Into Practice: Implementation and Physician Behavior Change
Evidence for the Effectiveness of Techniques To Change Physician Behavior

https://doi.org/10.1378/chest.118.2_suppl.8SGet rights and content

Study objectives

To understand the theory and results of how to improve physician performance, as part of overall health-care quality improvement. In particular, to study whether and how guideline production and dissemination affects physician performance.

Design

Review of meta-analyses and structured reviews; review of behavior change theories implicit in interventions to change physician performance.

Setting

Primarily the United States.

Patients or participants

Various patients and physicians, determined by reviews.

Interventions

None.

Measurements and results

There is no unifying theory of physician behavior change tested among physicians in practice. Attempts to affect individual physicians' performance have often met with failure. Mixed results are found for almost all interventions reviewed. Multiple interventions yield better results.

Conclusions

The answer to the question of what works to improve an individual physician's clinical performance is not simple. Emerging theory and evidence suggests that applications of behavior-change methods should not be focused on which tools (don't) always work. Instead, guideline development and implementation methods should be theory driven and evidence based (supported by evidence that proves the theory correct). In particular, the framework of evidence-based quality assessment offers some insight into past failures and offers hope for organizing attempts at guideline implementation.

Section snippets

The Rise (and Fall?) of Guideline Implementation Within Quality Improvement Programs

There has long been a clamor for an understanding of what works and what does not work to improve physician performance, as part of overall health-quality improvement.1234 The use of guidelines has become a popular, integral part of a reasoned approach to improving individual physician performance. A MEDLINE search lists 4,127 publications since 1966 under the publication category practice guideline, 3,969 of which were published since 1989. However, efforts to implement guidelines using tools

An Evidence-Based Approach to Review of Trials of Physician Behavior Change

Finding and employing methods to improve physician performance by changing physician behavior can be considered analogous to finding and employing drugs or other therapy to treat disease. The evidence-based medicine movement strongly asserts that randomized trials be accepted as the strongest evidence of the best therapy for a given disease. However, investigators evaluating interventions to improve individual physician performance have not held as rigorous a standard. Many studies used

Results and Discussions

Table 2 summarizes the findings of this review. A review of reviews by Bero44 is perhaps the most comprehensive single publication to date of the results of trials of physician performance improvement. A general review of all strategies to translate guidelines into practice by Davis and Taylor-Vaisey45 found that the likelihood of adoption of guidelines was influenced by several factors: qualities of the guidelines, characteristics of the health-care professional, characteristics of the

Conclusion

The reviews point to a few conclusions, but raise many questions, about the effectiveness of guideline implementation methods. Education in small doses (days) is ineffective, likely because it pales in comparison with the prior 20 years of education physicians have already received. Guideline dissemination is too passive to effect behavior change without active implementation strategies. Multiple implementation tools are more effective than single ones. Reminders may have the best evidence of

References (67)

  • The SUPPORT Principal Investigators

    A controlled trial to improve care for seriously ill hospitalized patients: the study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT)

    JAMA

    (1995)
  • Agency for Healthcare Research and Quality

    National Guideline Clearinghouse [online]

  • DA Katz

    Barriers between guidelines and improved patient care: an analysis of AHCPR's Unstable Angina Clinical Practice Guideline; Agency for Health Care Policy and Research

    Health Serv Res

    (1999)
  • J Kosecoff et al.

    Effects of the National Institutes of Health Consensus Development Program on physician practice

    JAMA

    (1987)
  • AG Randolph et al.

    Users' Guides to the Medical Literature: XVIII; How to use an article evaluating the clinical impact of a computer-based clinical decision support system

    JAMA

    (1999)
  • Evidence-Based Medicine Working Group

    Evidence-based medicine: a new approach to teaching the practice of medicine

    JAMA

    (1992)
  • Evidence-based care, 1: Setting priorities; how important is the problem? Evidence-Based Care Resource Group

    Can Med Assoc J

    (1994)
  • Evidence-based care, 2: Setting guidelines; how should we manage this problem? Evidence-Based Care Resource Group

    Can Med Assoc J

    (1994)
  • Evidence-based care, 3: Measuring performance; how are we managing this problem? Evidence-Based Care Resource Group

    Can Med Assoc J

    (1994)
  • Evidence-based care, 4: Improving performance; how can we improve the way we manage this problem? Evidence-Based Care Resource Group

    Can Med Assoc J

    (1994)
  • SH Woolf et al.

    Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines

    BMJ

    (1999)
  • PG Shekelle et al.

    Clinical guidelines: developing guidelines

    BMJ

    (1999)
  • Sickle Cell Disease Guideline Panel

    Sickle cell disease: screening, diagnosis, management, and counseling in newborns and infants; clinical practice guideline No. 6

    (April, 1993)
  • The Agency for Health Care Policy and Research Smoking Cessation Clinical Practice Guideline

    JAMA

    (1996)
  • C Cassel et al.

    ABIM Subcommittee on Clinical Competence in Women's Health: what internists need to know; core competencies in women's health

    Am J Med

    (1997)
  • ES Holmboe et al.

    Methods for evaluating the clinical competence of residents in internal medicine: a review

    Ann Intern Med

    (1998)
  • JM Walsh et al.

    A systems model of clinical preventive care: an analysis of factors influencing patient and physician

    Health Educ Q

    (1992)
  • R Grol

    Beliefs and evidence in changing clinical practice

    BMJ

    (1997)
  • BF Skinner
  • RW Putnam et al.

    Competence

  • SB Soumerai et al.

    Principles of educational outreach ('academic detailing') to improve clinical decision making

    JAMA

    (1990)
  • EM Rogers
  • Cited by (219)

    View all citing articles on Scopus
    View full text