How to ensure that healthcare professionals read clinical practice guidelines?

Laura Diego Del Río & Pedro Rey 

During the last decades, there has been a dramatic increase in the clinical information available to healthcare professionals and best-practice reference documents have been established in different areas of medicine. An example of this is the numerous clinical practice guidelines developed by various institutions. Despite the vast amount of criticism bout their limitations; their elaboration implied a great effort to establish quality standards and a significant publication of literature on adoption strategies in clinical practice. However, given this abundance of information, there are certain doubts about whether they are being read and followed through. Let us analyze the main reasons and see what can be done to change this (lack of) practice, under the prism of behavioural economics.

1. Information overload

The currently existing volume of guides is so high that it’s unmanageable. Moreover, it’s challenging to choose one, which at first may seem like a positive aspect, but is it? Such a variety of information can, in turn, contribute to raising doubts about the quality of all of them - which "cannot be the same" - or about possible conflicts of interest - depending on which institution promotes them - that skew the approach of the information offered. Given the difficulty of settling on one, one may be inclined not to decide on any. Let us see, for example, this classic experiment from the marketing area: customers of a supermarket may sample either one of six jars of jam of different flavours or one in 24. Surprisingly, the results observed in multiple similar tests show that Even though one might think that it’s easier to find the jam that one likes most among a higher number of flavours, the sales of jams are smaller the more choices people have. Transferring the results to clinical practice guidelines, concentrating the production of guides in recognized, specialized organizations with resources that guarantee methodological quality could help alleviate the problem.

2. Change of habits

The clinician's agenda is naturally demanding. They work in an environment where they have to make decisions about patients continuously and in stressful situations. In this context, it’s challenging to locate the necessary information in the available time, and it’s easier to follow the established habits. Introducing incentives that stimulate the change of specific practices, such as consulting a guide before deciding on a treatment, can work in some instances, but can also be interpreted as interference. In any case, well-designed incentives that promote a new type of clinical practice may only be necessary for a short period of time, since it’s difficult for us to change our customs and, once we have acquired the habit of consulting the guidelines, withdrawing the incentive does not necessarily mean that we change behaviour again.

3. Cognitive limitations and presentation effects

Clinical practice guidelines are produced by institutions whose fundamental concern is methodological quality rather than the actual usability of the guide by the end-user. Some of the information available in many of these guides is not intended precisely to help a healthcare professional make the best decision about a specific patient, making access to essential information more agile. For example, an audit conducted in 2005 in the United Kingdom showed that during a relatively quiet period, visits from 18 patients with a total of 44 diagnoses occurred, identifying 3,679 pages of detailed clinical practise guidelines with the immediate care of these patients. The date means that to attend them, it would take about 122 hours of reading, assuming that the professionals have spent two minutes reading each page. In this sense, it would be expedient if clinical practice guidelines would come accompanied by other simplified materials or infographics that facilitate understanding. There are good examples of quality guides that distil and concentrate the essential information on two pages and make them easily manageable during the consultation. Like most of the measures we propose, and as marketing experts do, design tests can be done on different ways of presenting randomly assigned information and directly assessing health outcomes.

4. Biases in the interpretation of the associated risks

People assume that only patients have problems with the interpretation of data, not their doctor, mainly because we need to grant authority to those who decide for us in something that scares us and about which we have little information. However, psychologists such as Gerg Gigerenzer, show the disparity of interpretations among health professionals about the real risks associated with the result of a clinical test. Similarly, as I noted in that post, doctors and health managers are also influenced by how the information of the associated risks is presented. Many are deciding based on the information being presented positively or negatively. Therefore, everything we can gain in simplification and objectivity in terms of presenting risks in clinical practice guidelines will contribute to their correct use.

5. Contradictory recommendations and multimorbidity

A large number of clinical practice guidelines available make it possible to find relatively contradictory recommendations for the same pathology, depending on the guide consulted. Besides, the guidelines focus mainly on the management and approach of a single isolated pathology. In reality, multimorbidity is the norm, rather than the exception, and even more so as our life expectancy increases. We estimate that 40% of patients over 80 years of age have been diagnosed with at least four chronic diseases, but in general, few guidelines assume that patients may suffer from other diseases. Some guidelines, such as COPD, heart failure or diabetes mellitus, take into account other possible comorbidities but generally don’t give recommendations on the management of patients with multimorbidity, for which reason the potential for medication-remedy or medication-disease interaction is high. Redesigning guides grouped by frequent and real clinical cases, instead of isolated pathologies, could make their use more useful, and even less dangerous.

6. Confidence and status quo biases

The so-called "status quo bias" leads us to prefer not to change a decision or custom even when circumstances change, which may be due to a need to reaffirm the image we have of ourselves or the one we project on others because we like to present ourselves as safe people. Who trusts an authority figure that needs to consult "a little book" to make a clinical decision? Similarly, we trust more in close colleagues than an outside authority. Many clinical practice doubts resolve through trusted colleagues who can quickly provide information and advice. Subsequently, traditions and customs appear between clinical services, and these are difficult to adapt and change when clinical evidence demands it.

In the best-case scenario, even after reading clinical practice guidelines, doctors find it challenging to change their habits. The health sector is extremely conservative, partly due to the risks it faces. Vinay Prasad, of whom we have spoken several times in this blog, describes in his book "Medical Reversal" that from the moment the evidence shows that a practice has no value; the inertia causes the practice to go on for as long as ten years after its inefficiency has been proven. In this context, favouring continuous, regulated training, with materials that instil confidence lasting for post-training use, can be crucial.

We must rethink, therefore, the number, design and objective of clinical practice guidelines so that, when read, they become a good ally of the healthcare professional. Another day we’ll talk about what can be done so that they are not only read but also put to good use.