Physician Non-Compliance in Periodic Diabetes Testing

Design. Descriptive study of self-assessed compliance with five measures of performance.

Participants. 85 internists volunteers. Data Collection. Self-review of charts (1755 patient encounters) of patients with type 2 diabetes mellitus; open-ended questions.

Findings: The physician reported not complying with the annual foot examination in 13%, annual lipid profile (15%) and retinal examination (17%). Among the five measures examined, noncompliance was most common for screening urinalysis (26%) and screening microalbuminuria (46%).

Discussion Points: "Compliance with so-called "best practices" is far from ideal. (1-3) The barriers lie in 3 domains: physician knowledge (lack of awareness, lack of familiarity, or oversight), physician attitudes (lack of agreement; lack of self-efficacy-that is, the belief that a physician can perform guideline recommendations; lack of outcome expectancy-that is, skepticism that complying with the guideline would help patients; or the inertia of previous practice), and external barriers. (4)"

"In most previous studies on physician compliance, the physician participants answered closed-ended survey questions, and this limited the scope of their responses to those hypothesized by the investigators. (4) Other methods used in the literature include focus groups, (5, 6) interview, (7) retrospective review of administrative data, (8, 9) and hypothetical clinical scenarios. (10, 11) But these previous studies focused on general barriers rather than on patient-specific (and encounter-specific) reasons for not following guidelines."

"To gauge physician compliance, we focused on five common conditions with substantial scientific evidence for disease management: diabetes, cholesterol screening, warfarin therapy, asthma, and congestive heart failure. The survey form used included questions on whether the physician had met six performance measures for type 2 diabetes. Five questions addressed whether the patient had received one of the following tests in the previous 12 months: dilated eye examination, lipid profile, comprehensive foot examination, urinalysis testing, or microalbuminuria testing. The final question, regarding glycosylated hemoglobin, asked, "Within the past 12 months, in which of the following quarters was this patient seen at least once? (make sure you identify both the quarter and the year). In addition, indicate quarters when this patient had at least one glycosylated hemoglobin test and the highest value for the quarter." Because this question resulted in ambiguous responses (i.e., physicians did not clearly distinguish between year and quarter visits, resulting in ambiguous assignments of glycosylated hemoglobin values), we discarded data for this sixth performance measure."

"Conscious Decision. Physicians may consciously choose not to follow a guideline because of clinical considerations. That is, in some instances, the comments suggested that the internist made a conscious decision not to follow a "best practice." A common rationale was that the patient had more pressing medical problems. Another was that the best practice did not apply to the patient either because of advanced age or established disease (e.g., blindness or renal failure)."

"Patient Nonadherence. In other instances, physician comments indicated that the patient declined to follow the indicated practice (e.g., failure to modify lifestyle, unwillingness to visit an ophthalmologist, or missing an appointment)."

"Systems Issues. There were other instances in which the physician comment indicated some discontinuity of care not clearly attributable to either the physician or patient (e.g., lack of communication between providers caring for the same patient, seasonal change in patient residence, or inadequate insurance coverage)."

"Oversight. The oversight category comprises instances in which physicians acknowledged forgetting to apply the best practice."

" In summary, QNet participants have provided some insights into why physicians do not always comply with best practices. Our data suggest that failure to follow guidelines is not necessarily explained by "bad doctors" or forgetfulness; rather, noncompliance may reflect valid questions about the usefulness and applicability of a best practice to an individual patient. As Vijan pointed out, "Not all patients are the same. Treating them as such not only minimizes autonomy but is also a recipe for inefficiency." (14) The difficult task for the future will be to determine how such factors as comorbid illness, age, and patient wishes can be incorporated into performance measures to more accurately reflect the intricacies of quality care in clinical practice."

The 85 internists who volunteered for this study are members of a practice-based research network called "QNet," which is short for Quality Network. The American College of Physicians-American Society of Internal Medicine (ACP-ASIM) created QNet to raise physician awareness of best practices and to provide a glimpse into the constraints and reality of everyday office-based care.

Pilson C, Snow V, Bartlett K. Physician Explanations for Failing To Comply with "Best Practices." Effective Clinical Practice, September/October 2001
Paraphrased from ACP-ASIM Online.
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