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Phil B.FontanarosaMD, Deputy EditorIndividualAuthorStephen J.LurieMD, PhD, Fishbein FellowIndividualAuthor
In Reply: Dr Veatch points out that physician
disagreement with the value judgments incorporated within a guideline may
be another reason for physician nonadherence. In our article, we found 33
surveys investigating physician disagreement with guideline-specific recommendations
as a barrier and 15 surveys investigating physician disagreement with the
general concept of guidelines.1 There are
many specific aspects of guidelines that physicians may find objectionable.
Although guideline authors have been urged to state their value judgments
explicitly,2 we found no studies that examined
disagreement with value judgments as a reason for guideline nonadherence,
as Veatch suggests. It is an interesting point that deserves study.
We agree with Dr Montgomery and colleagues that improved patient care
depends not only on physician use of guidelines, but also on accurate and
proper use of such guidelines. Using their example, our analytic framework
might be used to examine the reasons for inaccurate application of hypertension
guidelines by physicians, such as lack of familiarity with the guideline,
lack of agreement with the recommendations, the inertia of previous practice,
or external barriers such as lack of time or lack of a decision support system
to help correctly apply the guideline.
With respect to Dr Dahlberg's plea for concise guidelines, we reported
23 examples of barriers citing guideline format as a barrier to adherence.
In these examples, guidelines were described as difficult to use, inconvenient,
cumbersome, and confusing. We did not attempt to rate the relative importance
of the 293 total examples of barriers in our analysis. It may well be that
other physicians agree with Dahlberg that this barrier is the most important
and difficult to overcome.
Cabana MD, Rand CS, Powe NR, Wu AW, Abboud PC, Wilson MH. Reasons Physicians Do Not Follow Clinical Practice Guidelines—Reply. JAMA. 2000;283(13):1685–1686. doi:10.1001/jama.283.13.1685
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