Implementing joint treatment guidelines to improve prescribing in general practice Kasje, Willeke Nynke

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1 University of Groningen Implementing joint treatment guidelines to improve prescribing in general practice Kasje, Willeke Nynke IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below. Document Version Publisher's PDF, also known as Version of record Publication date: 2004 Link to publication in University of Groningen/UMCG research database Citation for published version (APA): Kasje, W. N. (2004). Implementing joint treatment guidelines to improve prescribing in general practice Groningen: s.n. Copyright Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons). Take-down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. Downloaded from the University of Groningen/UMCG research database (Pure): For technical reasons the number of authors shown on this cover page is limited to 10 maximum. Download date:

2 Chapter 3 Physicians views on joint treatment guidelines for primary and secondary care W.N. Kasje, P. Denig, P.A. de Graeff, and F.M. Haaijer-Ruskamp Objectives: Joint drug formularies and treatment guidelines have been developed to reduce problems arising at the interface between primary and secondary care. The aim is to compare the willingness of hospital specialists and general practitioners to use joint treatment guidelines, and to determine the most relevant barriers and facilitators. Design of study: A structured survey which consisted of questions about the use of guidelines and formularies in general, and possible barriers and facilitators for using a specific joint guideline. These specific guidelines concerned the treatment of hypertension, heart failure or diabetes mellitus. Setting and study participants: 197 general practitioners and 34 general internists and cardiologists from the North of the Netherlands. Results: Most hospital specialists relied for their prescribing on international guidelines and agreements within their own department, while general practitioners relied more on national and regional guidelines. General practitioners were more supportive than specialists of the initiative to develop joint treatment guidelines, although both groups had concerns regarding the development process. An important barrier for specialists was that they did not perceive a need for these guidelines. As enabling factors, physicians stated that these joint guidelines can lead to harmonisation between specialists and general practitioners, and that they can be useful as an educational tool. Conclusion: Specialists are less ready to adopt joint treatment guidelines than general practitioners, indicating the need for a different approach to implement such guidelines in the two sectors. International Journal for Quality in Health Care, Vol.16, 3: 1-8

3 Introduction Clinical practice guidelines are intended to support health care professionals, but too many different guidelines may be confusing rather than guiding. Despite the application of the same scientific evidence, guidelines issued by different organisations or in various countries do not always give consistent recommendations. 1-3 This can be a problem for the health care professional, who may become uncertain about which guideline to follow. It can also lead to confusion in patients who move between different levels of health care, in particular at the primary-secondary care interface. 4 This is especially relevant in health care systems such as the Dutch where the general practitioner (GP) acts as a gatekeeper, so that patients can only visit a specialist after referral by their GP. In many cases, the specialist can give advice and send the patient back to the GP for follow-up care. To enhance seamless and efficient health care, a number of researchers have recommended the development of joint formularies or treatment guidelines for primary and secondary care. 4,5 In the Netherlands, a programme was set up by the Ministry of Health, Well-being and Sports and supported by Health Insurance Funds to form joint treatment guidelines. Local committees of hospital specialists, GPs, and hospital and community pharmacists developed the guidelines. 6 At the time of our study, 16 guidelines for shared care had been developed as part of a regional joint formulary in the province of Groningen. 7 An implementation project was planned focussing on two issues, i.e. the treatment of chronic heart failure and the treatment of hypertension in diabetic patients. To develop an effective implementation strategy, it is important to know to what extent the target population opposes or supports the use of these guidelines. 8,9 In general, the motivation for using guidelines is related to the quality and reliability of the guideline and its development process, and a variety of barriers and facilitators at the level of the professional and the working environment Qualitative research among a small group of Dutch hospital specialists showed that potential barriers for using joint treatment guidelines can be found in all these domains. 6 The imp ortance of the revealed barriers is not clear yet, nor is it known whether specialists and GPs have similar views and attitudes. There might be differences in attitude and culture that are important for implementing changes. 13 The aim of this study is to assess the willingness of both hospital specialists and GPs to use joint treatment guidelines, and to determine the most relevant barriers and facilitators. A comparison will be made between both groups of physicians to determine whether an implementation programme should be tailored to each group separately. The questions addressed focus on the physicians current guideline use, their satisfaction with current practice, their support for the development of joint treatment guidelines in general, and perceived barriers and facilitators towards using one specific guideline. 34 Chapter 3

4 Methods Study population We set out to administer a structured questionnaire to all physicians for whom the specific joint treatment guidelines were relevant. These were all 260 GPs, 36 general internists and 24 cardiologists working in Groningen, a province in the North of the Netherlands. The questionnaire was distributed in two waves. The first wave took place in the autumn of 2000 at a series of educational meetings held yearly for both hospital specialists and GPs in this region. One of the topics during these meetings was to inform the physicians about the transmural project in general, and present one specific guideline in particular. We distributed and collected our questionnaire during these meetings. Since not all physicians attended the meetings and therefore had not received the questionnaire, the questionnaire was sent or handed out in a second wave between December 2000 and April 2001 to each of the remaining 97 GPs and 19 specialists who did not attend the educational meetings. Questionnaire The structured questionnaire consisted of a general and a guideline specific part. The general part included questions regarding background characteristics, current use of clinical treatment guidelines, followed by 3 statements regarding satisfaction with current practice and 3 statements regarding support for the project of developing joint guidelines. Regarding current use of guidelines, respondents could indicate how often they used specific guidelines, formularies or agreements. There are two sets of national guidelines in the Netherlands. For primary care, there are the NHG-guidelines developed by the Dutch College of General practitioners. For specialists, there are the CBO-guidelines developed by the Dutch Institute for Health Care Improvement. On a regional level, a drug formulary exists for GPs, and some regional specialists societies have a written agreement on some treatments. Small peer review groups in general practice may develop their own recommendations locally, as may specialists organised in partnerships and departments. The second part of the questionnaire included statements of possible barriers and facilitators for using one specific joint treatment guideline. The guidelines for chronic heart failure, hypertension and diabetes were used as examples, since the implementation programme would focus on these guidelines. The statements were phrased to specify one guideline, for example I do not need this guideline (for chronic heart failure). The specific guideline was presented to the respondents before they were asked to complete the questionnaire. The list of statements involved the four domains identified in previous research, focussing on (1) content of the guideline, (2) development process, (3) usefulness and value for practitioners, and (4) aspects of organisation and setting. 6,11,12 35 Physicians views

5 Statements from existing instruments, such as the Attitudes towards Guidelines Scale, 14 were supplemented with statements derived from an earlier qualitative study. 6 A questionnaire with 42 statements was pre-tested by three physicians for clarity and comprehensiveness. Two statements were excluded for being ambiguous or irrelevant. Agreement with all statements was quantified on a 7-point Likert scale, ranging from Strongly agree to Strongly disagree. Analysis Mann-Whitney tests were used to test for differences in agreement between specialists and GPs, and between responders to the first and second wave of data collection. Kruskal-Wallis tests were used to test for differences between responders confronted with different specific guidelines. Differences in guideline use were tested with Chi 2 -tests. The statements dealing with attitudes towards a specific guideline were re -coded so that low scores (1-3) were negative, the median score (4) was neutral and high scores (5-7) were positive towards guideline use. Numbers of specialists and GPs with negative, neutral or positive attitudes were compared with Chi 2 -tests. Cronbach s a was calculated to determine internal consistency between the items within each domain. For internally consistent domains, sum-scores were computed by calculating the mean score per item adjusting for missing values on individual items resulting in a scale from 1 (negative) to 7 (positive). Results More than half of all cardiologists (16 out of 24) and internists (18 out of 36), and three-quarters of all GPs (197 out of 261) in the region completed the general part of the questionnaire (Table 1). There were fewer respondents to the specific part of the questionnaire in the first wave, because at one meeting the participants did not receive one of the specific guidelines included in our study. The 197 GPs were on average 48 years old (SD 6.7), and 37 (19%) of the GPs were women. The mean age of the 34 specialists was 47 years (SD 7.5), and 3 (9%) of them were women. Responses to only 3 of the 40 items differed for physicians who answered the questionnaire during the educational meetings (wave 1) and physicians who did not attend these meetings (wave 2). Physicians from the first wave more often agreed that medical practice was oversimplified in the guideline (p=.005). On the other hand, they considered the guideline less often as being too restrictive (p=.027), or containing too many equivalent drugs (p=.042). For all further analyses, no distinction is made between data collected in wave 1 or wave Chapter 3

6 Table 1: Numbers of specialists and general practitioners responding to the questionnaire Specialists General practitioners N (response rate) 34 (57%) 197 (76%) General statements Wave 1 1 Wave 2 2 Specific statements Wave 1 Wave questionnaire was distributed and collected during educational meetings for specialists and general practitioners 2 questionnaire was sent to general practitioners and handed out to specialists who were not present at the educational meetings Figure 1. Current use of treatment guidelines hospital local local type of guideline regional regional national national international international response percentages specialists reporting regular use of guideline specialists reporting constant use of guideline GPs reporting regular use of guideline GPs reporting constant use of guideline 37 Physicians views

7 Current situation and general views Almost all specialists and GPs reported that they used some kind of treatment guideline regularly or always (Figure 1). Significantly more specialists than GPs reported frequent use of international guidelines and local agreements or recommendations, whereas significantly more GPs than specialists reported use of the national and regional guidelines (p<.001). A small majority of the physicians endorsed the view that primary and secondary care were well harmonised, but at the same time most physicians saw room for improvement (Table 2). Almost all physicians agreed that it was worthwhile to make joint treatment agreements, and many considered it not in the patient s best interest to switch drugs at the primary-secondary care interface. GPs supported the aim and importance of this specific project more than specialists. Table 2: General views of specialists and general practitioners on the current situation at the primary - secondary care interface; percentages of physicians agreeing with the questionnaire statements General statement Concerning the treatment of patients there is good harmonisation between primary and secondary care The quality of pharmacotherapy cannot further be improved Communication with specialists/general practitioners about patient treatment can be improved I subscribe to the project s aim and importance It is not in the patients best interest to switch drugs when crossing the primary-secondary care interface. Agree with statement Specialists (n=34) % GPs (n=197) % Chi 2 -test* (df=2) p= p= To make joint agreements on pharmacotherapy is worthwhile * comparing numbers of specialists and GPs agreeing, disagreeing or having a neutral opinion. Only p-values <.05 are reported Specific barriers and facilitators Regarding most barriers and facilitators, there were no significant differences between responses to the guideline on hypertension, heart failure or diabetes (data not shown). Only in the case of the diabetes guideline, d id a significantly greater number of respondents agree that its implementation is too time consuming and expensive (p=.004), and that it limits their professional autonomy (p=.005). 38 Chapter 3

8 Therefore, the answers for the three guidelines were taken together, and presented as such in Table 3. The domains content, usefulness and value, and organisation and setting had acceptable reliability scores for calculating sum-scores (alpha s 0.69, 0.76, and 0.64). On average, both groups of physicians were moderately positive regarding all domains (table 3), and there were no significant differences between the two groups. The reliability of the domain development process was too low (alpha = 0.42) to calculate sum-scores. Within the domain content, most physicians agreed that the recommendations in the joint treatment guideline were congruent with their daily practice, although not all agreed that good choices had been made within drug classes. Specialists in particular believed that recommendations should only be given on drug class level. Despite a high level of confidence that the guideline was evidence-based, some specialists considered the guideline to be too conservative. Some barriers were seen in the domain development process regarding the dominance of financial interests, and the distance between developers and practitioners. On the other hand, most physicians agreed that the guidelines were developed by experts. In the domain usefulness and value, both groups of physicians believed that the joint treatment guideline was useful as educational tool, was appropriately applicable in practice, could facilitate communication and improve harmonisation between primary and secondary care. Most GPs and a majority of the specialists agreed that the joint guideline was a good source of advice and could improve quality of care. There was less confidence that it would lead to cost savings. A clear barrier was the fear that the guideline could be misused by government and insurance companies. For at least half of the specialists, lack of need for the guideline, negative influence on innovation, and oversimplification of medical practice were identified as barriers. Some barriers were observed in the domain organisation and setting. A third of the specialists expected to lose industry support for conferences and research. In addition, specialists considered their practice organisation as less supportive of the guidelines than the GPs. On the other hand, GPs more than specialists saw a problem with patients not wanting to be treated according to the guideline. Discussion Our study showed that the specialists and the GPs in this study use different treatment guidelines, indicating a potential problem for the continuity of care. Most specialists relied on international guidelines and on agreements within their department. International guidelines often provide a detailed review of the evidence, whereas local agreements usually focus more on reducing drug variability or costs. 39 Physicians views

9 40 Chapter 3 Table 3: Percentages of physicians agreeing and disagreeing with specific statements about joint treatment guidelines Specialists (n=31) GPs (n=147) Agree Disagree 1 Agree Disagree Chi 2 -test 1 (df=2) Guideline content This guideline is based on scientific evidence p=.017 This guideline recommends what I already do in practice Within drug classes good choices have been made in this guideline p=.031 This guideline is outdated This guideline is too restrictive This guideline is too conservative p=.019 Too many equivalent drugs are included in this guideline This guideline should have given recommendations on drug class level only p=.010 Average of sum-score for domain content (scale 1-7) (s.d. 1.0) 4.5 (s.d. 0.7) - Guideline development process 3 The people in the developing committees were appropriate representatives of my professional group p=.004 This guideline is made by experts This guideline development initiative is too much dominated by financial interests The distance between the developers of these guidelines and practitioners is too big Usefulness and value of guideline This guideline is useful as an educational tool This guideline is a convenient source of advice p=.043 This guideline can facilitate communication with specialists / GPs p=.007 This guideline can facilitate communication with patients and families This guideline can improve the quality of pharmacotherapeutic care This guideline can lead to better harmony between primary and secondary care

10 41 Physicians views Table 3 (continued): Percentages of physicians agreeing and disagreeing with specific statements about joint treatment guidelines Specialists (n=31) GPs (n=147) Chi 2 -test 1 Agree Disagree 1 Agree Disagree (df=2) This guideline can lead to cost savings This guideline is well-applicable in practice This guideline facilitates taking over patients from colleagues This guideline can be misused by government and insurance companies This guideline limits innovation p=.016 I do not need this guideline p=.005 This guideline challenges my professional autonomy This guideline oversimplifies medical practice p=.045 Many of my patients can not be treated according to this guideline Average of sum-score for domain usefulness/value (scale 1-7) 4.3 (s.d. 0.0) 4.5 (s.d. 0.6) - Organisation and setting Most of my colleagues have disapproving attitudes about this guideline This guideline is not valued in my practice organisation p=.013 To implement this guideline is too time consuming and expensive With this guideline I lose industry support for conducting research p<.001 With this guideline I lose industry support for conferences and educational meetings p=.010 Some of my patients do not want to be treated according to this guideline p=.013 This guideline thwarts local guidelines and agreements Average of sum-score for domain organisation/setting (scale 1-7) 4.5 (s.d. 1.1) 4.6 (s.d. 0.9) - 1 scores for neutral responses have been omitted; chi-2 comparing of specialists and GPs agreeing, disagreeing or having a neutral opinion. Only p- values <.05 are reported 2 sum-scores were computed by calculating the mean score per item adjusting for missing values. Scale 1-7 refers to a negative score (1) and to a positive score (7) 3 reliability score of this domain was too low (α=0.42) to calculate sum-scores

11 Most GPs reported use of a regional formulary or national guidelines for their prescribing, which both aim at stimulating rational and cost-effective prescribing. This preference of GPs in the Netherlands for national and local guidelines over international ones is similar to preferences found in other countries. 15 The finding that both specialists and GPs reported frequent use of local or regional guidelines may be related to feelings of ownership. Moreover, peer pressure may be an additional factor facilitating implementation of local guidelines. Joint treatment guidelines could enable the harmonisation of pharmacotherapy at the primary-secondary care interface. 4,5 There are only a few examples of joint drug formularies, such as in the Lothian and Grampian regions in Scotland. Their implementation may have been stimulated by the fact that budget responsibilities for hospital and primary care in Scotland were held by one authority, 4 which differs from many other countries including the Netherlands. Organisational policies and procedures, as well as enforcement can increase adherence to guidelines. 16,17 When there are no external pressures, the motivation to use guidelines has to come from the physicians themselves. The perceived need to use a new guideline depends on the physician s satisfaction with the current situation and the perceived efficacy of the recommended change. 11,18 The change should make sense, and people involved must be trusted and respected. 19 Both specialists and GPs in our study believed that improvements could be made in communication, harmonisation and quality of pharmacotherapy by making and using joint treatment guidelines. However, GPs seemed more supportive of the project than specialists, and more motivated to use the newly developed guidelines. Problems associated with switching drugs may be more noticeable in general practice. GPs sometimes feel unable to take responsibility for certain treatments started by specialists, and reluctant to make changes. 20,21 This poses problems given the current policy debate in primary health care where GPs are given more responsibility in the treatment of chronic patients. Specialists were more critical regarding the conservative and limiting nature of guidelines, and expected more negative consequences, such as loss of industry support. These barriers for specialists were already identified in an earlier exploratory study, but their relevance was not clear. 6 This current study shows that more than a third of the specialists worried about losing good research opportunities provided by the industry. In addition, more than half of the specialists particularly stated that they did not need these guidelines. Guidelines are especially appropriate in situations where physicians are uncertain about the most effective way of treating a disease. 22 A surplus of self-efficacy, however, could form a barrier. Although most physicians were positive regarding the content of the guidelines, they were concerned about the development and implementation process. They were afraid that the guidelines could be misused by government and insurance companies, and distrusted the financial interests. This distrust is probably linked to 42 Chapter 3

12 the fact that one of the goals of these guidelines is reduction of clinical variability and costs. The feeling of suspicion and a government ploy to discipline physicians has been seen before and is associated with a negative attitude of the physicians. 23 Limitations Using a questionnaire is an efficient way to examine beliefs and barriers in a structured way. Our questionnaire was based on the validated Attitudes towards Guidelines Scale. 14 The four domains included coincide with previously suggested theoretical domains. 11 Socially desirable answers are a common problem in this type of research. We have tried to limit this by using positive as well as negative statements, and by emphasizing that the data would be processed anonymously. The response rate was relatively high, but somewhat lower among specialists than GPs, which could be due to the fact that specialists were less interested in this subject of joint treatment guidelines. The diffe rent ways of data collection could be considered a limitation of our study. However, we found no differences in the majority of responses between the two waves of data collection, allowing us to analyse the data together. Another limitation is that the physicians had not yet worked with these joint treatment guidelines. We did present them with an example of one guideline, so that they could form an opinion on that specific guideline. We used three different examples, but found that there were no major differences in opinion. Only regarding the diabetes guideline, physicians were more concerned about their autonomy and the efforts needed for implementation. It is possible that a guideline on a completely different (non-cardiovascular) subject might elicit different barriers and facilitators. Implications Improving continuity of healthcare has been put on the agenda by governments as well as professional general practitioner organisations in Europe. In several regions, joint drug formularies or guidelines have been developed and new initiatives are being taken, but little is known about the physicians motivation to use joint guidelines. Our results indicate that specialists have a different readiness for implementing these guidelines than GPs. The specialists in our study do not see many problems in the current situation, nor do they see much need to use such guidelines themselves, which implies that they are still at the stage Prochaska has termed the precontemplation stage of behavioural change. 18 This stage represents those individuals who have no desire to change their behaviours in the immediate future. For them, joint guidelines are not needed as review of the evidence. This might be a universal problem, as specialists by definition should have extensive knowledge within their specialty. An implementation programme for specialists should focus on the objective of harmonisation between primary and 43 Physicians views

13 secondary care, starting with making them aware of the extent and nature of the current problems at the interface. The GPs in our study seem to be in the contemplation stage, aware of the problem and having a positive attitude towards using joint guidelines. For them it is important to focus on how to apply the recommendations in practice, addressing some specific barriers perceived, for instance, how to deal with uncooperative patients. The GPs awareness and positive attitude towards joint guidelines may be related to a health care system where patients frequently switch between primary and secondary care. For both groups of physicians, it seems necessary to address the distrust regarding financial objectives, and focus more on quality of care than on cost savings. References 1 Burgers JS, Bailey JV, Klazinga NS, Van Der Bij AK, Grol R, Feder G. Inside guidelines: comparative analysis of recommendations and evidence in diabetes guidelines from 13 countries. Diabetes Care 2002; 25(11): Iqbal A, Schloss S, George D, Isonaka S. Worldwide guidelines for chronic obstructive pulmonary disease: a comparison of diagnosis and treatment recommendations. Respirology 2002; 7(3): Koes BW, Van Tulder MW, Ostelo R, Kim BA, Waddell G. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine 2001; 26(22): Duerden M, Walley T. Prescribing at the interface between primary and secondary care in the UK. Towards joint formularies? Pharmacoeconomics 1999; 15(5): Kvamme OJ, Olesen F, Samuelsson M. Improving the interface between primary and secondary care: a statement from the European working party on quality in family practice (EQuiP). Qual Health Care 2001; 10(1): Kasje WN, Denig P, Haaijer-Ruskamp FM. Specialists' expectations regarding joint treatment guidelines for primary and secondary care. Int J Qual Health Care 2002; 14(6): Proeftuin Farmaceutische Zorg. Towards the Groningen joint formulary (in Dutch). Groningen, Grol R, Jones R. Twenty years of implementation research. Fam Pract 2000; 17 (Suppl 1): S32-S35. 9 Wensing M, Van der Weijden T, Grol R. Implementing guidelines and innovations in general practice: which interventions are effective? Br J Gen Pract 1998; 48(427): Thorsen T, Makela M. Changing professional practice. Theory and practice of clinical guidelines implementation. Copenhagen, DSI: Danish Institute for Health Services Research and Development, Chapter 3

14 11 Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MD, Abboud PA, et al. Why don't physicians follow clinical practice guidelines? JAMA 1999; 282(15): Langley C, Faulkner A, Watkins C, Gray S, Harvey I. Use of guidelines in primary care-practitioners' perspective. Fam Pract 1998; 15(2): Evans D. A stakeholder analysis of developments at the primary and secondary care interface. Br J Gen Pract 1996; 46(412): Elovainio M, Eccles M, Makela M. Attitudes towards guidelines and a scale for measuring them. In Changing professional practice. Copenhagen, DSI: Danish Institute for Health Services, Hobbs FR, Erhardt L. Acceptance of guideline recommendations and perceived implementation of coronary heart disease prevention among primary care physicians in five European countries: the Reassessing European Attitudes about Cardiovascular Treatment (REACT) survey. Fam Pract 2002; 19(6): Ward MM, Vaughn TE, Uden-Holman T, Doebbeling BN, Clarke WR, Woolson RF. Physician knowledge, attitudes and practices regarding a widely implemented guideline. J Eval Clin Pract 2002; 8(2): Pathman DE, Konrad TR, Freed GL, Freeman VA, Koch GG. The awareness-toadherence model of the steps to clinical guideline compliance. The case of pediatric vaccine recommendations. Med Care 1996; 34(9): Prochaska JO. Systems of psychotherapy: a transtheoretical analysis, 2nd ed. Dorsey: Homewood, Ill., Armstrong D, Reyburn H, Jones R. A study of general practitioners' reasons for changing their prescribing behaviour. BMJ 1996; 312(7036): Sibbald B, Wilkie P, Raftery J, Anderson S, Freeling P. Prescribing at the hospitalgeneral practice interface. II: Impact of hospital outpatient dispensing policies in England on general practitioners and hospital consultants. BMJ 1992; 304(6818): Horne R, Mailey E, Frost S, Lea R. Shared care: a qualitative study of GPs and hospital doctors views on prescribing specialist medicines. Br J Gen Pract 2001; 51(464): Hurwitz B. Guidelines, judgement, opinion, and clinical experience. Qual Health Care 2001; 10(4): Johnston G, Crombie IK, Davies HT, Alder EM, Millard A. Reviewing audit: barriers and facilitating factors for effective clinical audit. Qual Health Care 2000; 9(1): Physicians views

15 46 Chapter 3