When there is too much to do: how practicing physicians prioritize among recommended interventions

Abstract

Background: Recent evidence suggests that patients are receiving only 50% of recommended processes of care. It is important to understand physician priorities among recommended interventions and how these priorities are influenced both intentionally as well as unintentionally.

Methods: A survey was mailed to all primary care physicians (PCPs) from two VA hospital networks (N= 289), one of which had participated in a broad, evidence-based guideline development effort 8 to 12 months earlier, and all endocrinologists nationwide in the VA (N= 213); response rate, 63% (n= 315). Using the method of paired comparisons, we assessed physician priorities among 11 clinical triggers for interventions in the management of an uncomplicated patient with type 2 diabetes.

Results: Both PCPs and specialists consistently identified several high-impact clinical triggers for treatment as the highest priority interventions (hemoglobin A1c = 9.5%, diastolic blood pressure [DBP]= 95 mm Hg, low-density lipoprotein = 145 mg/dl). Several low-impact interventions that are commonly used as performance measures also received relatively high ratings. Treatments that have recently been found to be highly beneficial were often rated as being of low importance (e.g., treating when DBP = 88 mm Hg). Almost 80% of PCPs rated tight glycemic control as more important than tight DBP control, in direct contrast to clinical trial evidence. Specialists' ratings followed the same general pattern, but were more consistent with the epidemiological evidence. The PCPs at the sites that participated in the guideline intervention rated blood pressure control significantly higher.

Conclusion: Although several high-priority aspects of diabetes care were clearly identified, there were also notable examples of ratings that were clearly inconsistent with the epidemiological literature. Recommendations based upon more recent evidence were substantially underrated and some guidelines used as performance measures were relatively overrated. These results support the arguments that a more proactive approach is needed to facilitate rapid dissemination of new high-priority findings, and that intervention priority, and not just ease of measurement, should be considered carefully when disseminating guidelines and when selecting performance measures.

FIGURE 1

Information scenario.

FIGURE 2

Prioritization of diabetes interventions by physician group. The higher the clinical trigger is on the y-axis, the higher its priority rating. A 1-unit higher rating denotes a 73% greater probability of being selected, and a 2-unit higher rating denotes an 88% higher probability. For example, in Figure 2A, a diastolic blood pressure of 95 mm Hg is 1.8 units higher than an A1c of 8.0% and thus 85% of the time PCPs would choose to intervene for the elevated blood pressure as compared to the Hgb A1c of 8. Figures 2B and 2C show the results broken out for endocrinologist (specialists), a group of generalist physicians who received no specific intervention (control PCPs), and a group of primary care physicians who received an intervention designed to increase attention to interventions directed at preventing macrovascular complications (intervention PCPs). Relative to the model for All Physicians, the model that estimates separate priorities for the 3 physician groups results in improved fit (P < .001). The arrows indicate the individual comparisons that were statistically significant.