Why Physicians Don’t Always Follow Best Practices

What to do for someone with swimmer’s ear is, by now, very clear: Use antibiotic eardrops. The issue has been settled in the literature and in expert reviews of the evidence. Oral antibiotics not only tend not to work, but they also promote antibiotic resistance, too (Otolaryngol Head Neck Surg. 2014;150(1 Suppl):S1-S24).

But, frequently, this guideline is not followed. “I cannot tell you how many people have been put on several different oral antibiotics as first-line medical intervention,” said Wendy Stern, MD, a physician at Southcoast Hospital Group in Dartmouth, Mass., and immediate past chair of the board of governors of the American Academy of Otolaryngology–Head and Neck Surgery. “It comes down to pressure not to refer to the specialist. Many patients are treated at walk-in and urgent care centers and by mid-level providers and physicians who may not know the guidelines. By the time they come to us, they have a significant problem, where if they had been treated with antibiotic ear drops they probably would have gotten better very quickly.”

Many of these patients experience compromised hearing and miss work or school due to severe pain. Often the ear canal is so swollen by the time we see them we’re at the point of putting wicks in their ears,” Dr. Stern said. “Sometimes it’s complicated by a fungal infection on top of a bacterial infection. It’s a whole variety of things.”

Dr. Stern, now working on guidelines on the adult neck mass, emphasized that she was speaking only for herself, not representing the academy.

Even in cases where the evidence has made the optimal treatment obvious, best practices for otolaryngology care are often not followed. And not just by primary care or community physicians. A noteworthy percentage of otolaryngologists don’t follow guidelines, either, studies have found, although it is hard to get solid data on guideline adherence across the field.

Every day, I have at least 10 emails of different things that I’m supposed to review. I worry that when academies come out with guidelines mixed in the queue of all of these emails that need to be opened up, something has to give. How much are you going to read? Employed physicians have so many additional mandates within their own system to follow, it is hard to find the time to read everything. —Wendy Stern, MD

“Guidelines are followed, but I think inconsistently,” said David Tunkel, MD, chair of pediatric otolaryngology at Johns Hopkins and the current chair of the AAO-HNS Guidelines Task Force.

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.

Jeremy Meier, MD, assistant professor of surgery in the division of otolaryngology-head and neck surgery at the University of Utah School of Medicine in Salt Lake City, whose research has found that many surgeons still routinely give antibiotics for tonsillectomy despite a guideline recommending against that practice, said physicians need to be made aware of their outcomes and guideline adherence. “Surgeons need to know their own data and their own outcomes,” he said. “Anecdotally, they may think that they’re providing the best practice, but if they truly were to go back and look at their outcomes, they may see that giving the antibiotics or not really didn’t make a difference.”

Dr. Stern said that the nonstop onslaught of emails that physicians receive daily, along with pressure to comply with insurance and quality measures, means that guidelines can get lost in the shuffle. “Every day, I have at least 10 emails of different things that I’m supposed to review,” she said. “I worry that when academies come out with guidelines mixed in the queue of all of these emails that need to be opened up, something has to give. How much are you going to read? Employed physicians have so many additional mandates within their own system to follow, it is hard to find the time to read everything.”

Involving Patients

She said the AAO-HNS is hard at work making sure the guidelines are accessible to everyone—healthcare providers and patients alike. She would welcome a universal electronic health record with guideline information embedded as a way to make sure physicians are informed. but acknowledged that goal is clearly easier said than done

Dr. Stern is now working on making guidelines more accessible to healthcare providers and more easily searchable online. “One of the things that I myself have discovered is that if I try to use lay terms to search some of our older guidelines, they are not as accessible as you’d like them to be to a patient,” she said. “A lot of other things come up first. Patients are our partners in good healthcare and our guidelines are accompanied with great patient-oriented summaries. We need to make sure that the patient can find them easily.”

Dr. Tunkel agreed, noting that guidelines are developed with patient representatives involved and already come with a plain-language summary intended for patient consumption.

Jerry Schreibstein, MD, an otolaryngologist at Ear, Nose and Throat Surgeons of Western New England in Springfield, Mass., who helped develop guidelines on voice improvement after thyroidectomy, said that the difficulty in persuading some patients that guidelines should be followed is a cause for non-adherence “more than we realize.”

“One of the biggest barriers is convincing patients that what you’re doing is appropriate,” he said. “In the case of differentiating an acute URI [upper respiratory infection] from sinusitis, it takes more time to educate the patient that they might not need antibiotics than it does to prescribe the medication. The patient may have the expectation they will get a medication or imaging and when we order antibiotics, a CT scan, or a procedure inappropriately, it just reinforces in their mind [that] they have sinus disease.

In private practice, he said, it helps to have a guidelines “champion” in the office who stays on top of guidelines and distributes information to the rest of the group. “The Academy tries to disseminate information the best way possible,” he said. “But I think we all know you need to hear things seven times and seven different ways to get a sense of what’s happening.”

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Thomas Collins is a freelance medical writer based in Florida.