El Surgery/Chemo ■ Surgery/RT/Chemo

□ Surgery/RT Surgery

El Surgery/Chemo ■ Surgery/RT/Chemo

□ Surgery/RT Surgery colon and lung cancer.91 This study, jointly sponsored by the Rand Corporation and the American Society of Clinical Oncology, will document the compliance of medical oncologists in the United States with two practice recommendations that are well supported in the medical literature and are considered standard care.

Alteration of Physician Practice Patterns

Thus far, we have described the complexity of many cancer treatment decisions. We have reviewed some of the data pertaining to variability in treatment patterns for multiple medical conditions, including cancer. We have shown that in some situations this variability reflects the absence of a single correct evidence-based approach, whereas in other situations the deviation from an established standard practice constitutes a lapse in quality of care.

In an effort to encourage uniformity of care when a best practice does exist, several strategies have been employed. These include the following:92

Didactic continuing medical education presentations Distribution of consensus conference recommendations Individualized physician education (academic detailing) Active participation in guideline development Physician feedback specific to his/her prior treatment decisions

Reminders encountered by physicians in the course of active patient care

Several studies have shown that neither traditional didactic continuing education programs nor the dissemination of patient care guidelines is effective in altering physician behavior.93-97 Following the national distribution in Canada of a consensus statement pertaining to the use of cesarean section, physician acceptance was measured.98 Surveys demonstrated that only 67% of targeted physicians were aware of the recommendations, and rates of cesarean section declined only slightly. Following the dissemination of the

Joint National Committee VI Hypertension Treatment Guidelines in the state of New York, physician compliance was found to be approximately 52%.99 The distribution of guidelines for the management of community-acquired pneumonia to physicians at the Massachusetts General Hospital resulted in a 56% rate of compliance.100 Poor adherence of surgeons to guidelines concerning breast cancer management has been demonstrated.

Several other interventions have been shown to be more effective. When physicians are used individually to educate colleagues, some change in behavior has been observed.101-103 Reminders in the chart specific to individual patients have been shown to be more effective than general reminders or lectures.104-106 Recruitment of local physician opinion leaders to advocate a particular change and/or provision of specific feedback concerning their compliance with guidelines can also alter behavior.107-111 Involvement of physicians in the process of local guideline development can be effective as well.112

Several authors have attempted to explain the difficulties that are encountered in attempting to change physician practice.113 Smith suggests that the many years of formal education and postgraduate training to which physicians are exposed, as well as their own practice experience, result in the establishment of somewhat rigid practice patterns that are difficult to alter.114 He notes that the multitude of printed materials to which physicians are exposed may actually desensitize them to new educational content.

Grol proposes that the most effective strategy for altering physician practice patterns should include the integration of several techniques (Table 14.1).115 These methods include (a) provision of scientific evidence in the development of guidelines, (b) interactive rather than "top down" physician education, (c) ongoing monitoring of clinical performance and provision of feedback to physicians, and (d) patient empowerment. Greco adds that physician opinion leaders, financial incentives, financial penalties, and administrative rules are influential as well.116

TABLE 14.1. Effects of different strategies to improve patient care.
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