Physician explanations for failing to comply with "best practices"

Abstract

Context: Substantial effort has been devoted to improving physician compliance with evidence-based guidelines.

Objective: To explore physicians' reasons for not following so-called "best practices" in caring for patients with type 2 diabetes.

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

Participants: Eighty-five internists who volunteered to participate in a practice-based research network created to improve clinical practice.

Data collection: Physicians reviewed their own charts of patients with type 2 diabetes mellitus (1755 patient encounters) to assess compliance and offered open-ended comments concerning their reasons for not complying with "best practices."

Results: The physician volunteers reported not complying with the annual foot examination in 13% of encounters. A similar level of noncompliance was reported for the 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%). The physicians' open-ended comments suggested that physician oversight, patient nonadherence, and systems issues were common reasons for noncompliance. However, noncompliance also resulted from a conscious decision by the physician, as indicated by comments about patient age and comorbid illness or, with nephropathy screening, established renal disease or current therapy with angiotensin-converting enzyme inhibitors.

Conclusions: Even among a self-selected group of physicians, noncompliance with best practices in diabetes is common. Although physician forgetfulness and external factors are frequently offered as reasons for noncompliance, it may also result from a conscious decision, as physicians may disagree about what constitutes "best practices."