The challenges of automating a real-time clinical practice guideline.

OBJECTIVE: To elucidate the types of problems encountered during implementation of a World Wide Web-based clinical practice guideline to manage hyperbilirubinemia in newborn infants. DESIGN: Formative assessment of an automated clinical-practice guideline in a large-scale implementation. SETTING: Primary-care clinics and offices, inpatient clinics, and emergency department affiliated with an academic children's hospital. PARTICIPANTS: General pediatricians, neonatologists, pediatric nurses, and computer scientists. RESULTS: Existing guidelines for hyperbilirubinemia management could not be translated directly into web pages. Modifications of the original guidelines were required to represent the clinical intent of the guidelines accurately. In addition, the automated guideline was augmented to incorporate a mechanism for generating clinical encounter forms in order for the system to be accepted into the clinical work flow. Other clinical considerations that influenced the final form of the automated guideline included limitations of computer resources and time constraints during patient encounters. CONCLUSIONS: Many existing guidelines are not amenable to straightforward implementation in automated systems. Strategies to increase the efficacy of the automated guidelines included guideline modifications, as well as careful consideration of the flow of clinical work. Repeated cycles of development and pilot testing are needed to design methods to accommodate the constraints imposed by clinical use.

Attitudes about clinical practice guidelines in a mixed model HMO: the influence of physician and organizational characteristics.

OBJECTIVE: This study assesses physician attitudes toward clinical practice guidelines, in an organization where guidelines have long been incorporated into the clinical practice. Attitudes toward institutional guidelines and guidelines in general are explored, and are compared to a published study describing attitudes among a sample of American College of Physician (ACP) members. DESIGN: Descriptive study. SETTING: A large, mixed model HMO. SAMPLE: Two hundred and three internists and family practice physicians. MEASURES: Attitudes toward perceived compliance with clinical practice guidelines were assessed. Summary measures of attitudes and anticipated impact of guidelines were created. RESULTS: Overall, attitudes toward practice guidelines among HMO physicians were very positive. Differences were observed by gender, practice model, years in practice and residency training. HMO physicians on average held more favorable attitudes toward guidelines compared with published results of an ACP survey. While HMO physicians in independent group practices viewed the concept of guidelines less favorably than staff model physicians, they were more likely to view the impact of guidelines positively than were the ACP physicians. CONCLUSIONS: Exposure to practice guidelines in the context of clinical practice can lead to positive attitudes about those guidelines. While resentment toward a system which relies on practice supports such as guidelines may remain among some physicians, this need not be inconsistent with an appreciation of the potential value of guidelines for improving clinical quality.

Influence of knowledge and attitudes on the quality of physicians' transfusion practice.

Studies evaluating relationships between physician background characteristics (e.g. years of practice and medical training) and quality of care have found few consistent associations. Site of practice variables have been better predictors of quality than have characteristics of individual physicians. This study explores the relationship between physicians' knowledge and attitudes regarding the use of blood products, and the quality of their transfusion practice, based on in-depth physician interviews and medical record reviews. The sample includes 296 transfusion episodes ordered by 17 physicians in 2 teaching hospitals. The physicians had participated in a larger survey of staff surgeons and anesthesiologists in these hospitals. The quality of transfusion practice was defined as the proportion of a physicians' transfusion episodes scored as justified, as determined by explicit chart audit plus implicit physician review. Large baseline differences were observed between the 2 hospitals; 48% of transfusions in hospital A were justified compared with 81% in hospital B. At the physician level, knowledge of transfusion indications and receptivity to input from colleagues were significantly associated with higher quality transfusion practice (standardized betas = 0.41 (P = 0.01), and 0.40 (P = 0.02), respectively). These findings suggest that in addition to organizational context, physician characteristics may be associated with the quality of care related to a specific clinical practice.

A randomized trial of a program to reduce the use of psychoactive drugs in nursing homes.

BACKGROUND: Although psychoactive medications have substantial side effects in the elderly, these drugs are used frequently in nursing homes. Few interventions have succeeded in changing this situation, and little is known about the clinical effects of such interventions. METHODS: We studied six matched pairs of nursing homes; at one randomly selected nursing home in each pair, physicians, nurses, and aides participated in an educational program in geriatric psychopharmacology. At base line we determined the type and quantity of drugs received by all residents (n = 823), and a blinded observer performed standardized clinical assessments of the residents who were taking psychoactive medications. After the five-month program, drug use and patient status were reassessed. RESULTS: Scores on an index of psychoactive-drug use, measuring both the magnitude and the probable inappropriateness of medication use, declined significantly more in the nursing homes in which the program was carried out (experimental nursing homes) than in the control nursing homes (decrease, 27 percent vs. 8 percent; P = 0.02). The use of antipsychotic drugs was discontinued in more residents in the experimental nursing homes than in the control nursing homes (32 percent vs. 14 percent); the comparable figures for the discontinuation of long-acting benzodiazepines were 20 percent vs. 9 percent, and for antihistamine hypnotics, 45 percent vs. 21 percent. In the experimental nursing homes residents who were initially taking antipsychotic drugs showed less deterioration on several measures of cognitive function than similar residents in the control facilities, but they were more likely to report depression. Those who were initially taking benzodiazepines or antihistamine hypnotic agents reported less anxiety than controls but had more loss of memory. Most other measures of clinical status remained unchanged in both groups. CONCLUSIONS: An educational program targeted to physicians, nurses, and aides can reduce the use of psychoactive drugs in nursing homes without adversely affecting the overall behavior and level of functioning of the residents.

Influence of clinical knowledge, organizational context, and practice style on transfusion decision making. Implications for practice change strategies.

Evidence shows that blood products, like other health care resources, are often used inappropriately, but the reasons for this have not been well studied. We conducted a face-to-face survey of 122 general surgeons, orthopedic surgeons, and anesthesiologists in three hospitals to evaluate the influence of several clinical and nonclinical factors on transfusion decision making. We found widespread deficiencies in physicians' knowledge of transfusion risks and indications. Each transfusion risk was estimated correctly by fewer than half of the physicians surveyed, and only 31% responded correctly to a set of four questions regarding transfusion indications. Attending physicians routinely had lower knowledge scores than did residents, yet they exhibited more confidence in their knowledge. Residents' transfusion decisions, however, were strongly influenced by the desires of their attending physicians, resulting in their ordering potentially inappropriate transfusions. Of the residents surveyed, 61% indicated that they ordered transfusions that they judged unnecessary at least once a month because a more senior physician suggested that they do so. These findings provide insights for the development of strategies to improve transfusion practices, which would address the dual concerns of quality of care and cost containment.