Why Physicians Don’t Always Follow Best Practices

A new study on compliance with AAO-HNS sudden sensorineural hearing loss guidelines, conducted through the CHEER (Creating Healthcare Excellence through Education and Research) Network, found that otolaryngologists follow many of the guideline recommendations at least 90% of the time. Among non-otolaryngologists, compliance was below 45% for three of the items. The researchers concluded that, while there is high compliance on some items, “there is significant room for improvement.”

Experts involved in creating guidelines, who stress that they are only broad evidence-based recommendations that cannot take into account every situation and nuance that physicians and patients may face, point to a wide variety of reasons why guidelines are sometimes not followed:

• Lack of information. Sometimes, the information either doesn’t get to physicians or isn’t absorbed. This is especially true outside the otolaryngology specialty.
• The “recency” effect. If a physician has had a recent bad experience with a patient despite following practice recommended in a guideline, he or she may be less inclined to follow the guideline later.
• Patient resistance. Even when presented with the reasons a certain treatment strategy is not appropriate, a patient might insist on that strategy anyway.
• Insurance barriers. Sometimes insurance might resist paying for or decline to pay for care recommended in a guideline, such as imaging in a timely manner.
• Access to medication. A medication shortage could make it difficult for physicians to access the medications recommended by a guideline.
• Willingness or ability to pay. Sometimes, a patient might not want to pay the out-of-pocket amount that’s required to move forward with care recommended by a guideline.
• Slow adopters. With any innovation, there will be some people who are slow to change, even if they are aware of the evidence and the recommendation.

Making Guidelines More Widely Available

Dr. Tunkel said that the AAO-HNS makes an effort to give lectures on guidelines at meetings, makes slide shows available on its website, and involves other disciplines in the development of guidelines so that they are as comprehensive and as widely relevant as possible. But there is still work to do to disseminate the information.

“I think guidelines, in and of themselves, published in a medical journal is probably not a very good way of encouraging adherence or acceptance of a guideline. We need to incorporate [them] into clever ways of implementing things,” Dr. Tunkel said. “There’s still a group of physicians who don’t know about guidelines when they get published. And so the Academy tries to do that with the website. They also try to involve as many people as they can into the development of guidelines.” For instance, with the AAO-HNS tinnitus guidelines, hundreds of suggestions were made during the peer review and public comment period, which led to improvement of the guidelines, he said.