Change practice patterns without ruffling feathers
Confidential, supportive environment essential
There is no perfect recipe for getting doctors to change their practice patterns, but a few ingredients appear to be essential: nonthreatening peer review, usable practice guidelines, and adjusted data that support the move toward change.
A good example of how such change can be accomplished is the Maine Medical Assessment Foundation (MMAF), founded in 1989. The foundation is the hub of a number of studies tracking outcomes and utilization rates from the state's medical practices. MMAF analyzes the data and develops practice guidelines. Currently in progress are four studies: The Maine Prostate Study, The Maine Women's Health Study, The Maine Carpal Study, and The Maine Lumbar Spine Study.
The success of the studies can be attributed to participation of private-practice physicians and the incorporation of patient-derived reports of care outcomes. Funding comes from private and federal grants, as well as support from Maine physicians, hospitals, insurance plans, businesses, and private individuals.
The nonprofit MMAF evolved from the pioneering work of Daniel Hanley, MD, John Wennberg, MD, and colleagues, who in the early 1970s documented the variations in practice and utilization patterns in medical care.1
Their small area analysis methods gave consumers and providers the tools to question variations in the rates of medical procedures among communities with similar populations.
Researchers adapted the small area analysis to larger geographic regions. In 1990, one study reported that lumbar fusion was performed 180% more frequently in midwestern states than in the northeast.2
The Maine Lumbar Spine Study just celebrated its eighth year, making it the longest running prospective cohort study of lumbar disc herniation and spinal stenosis in North America. Involving 600 patients, it examines outcomes of surgical and nonsurgical treatments of spine conditions.
Follow-up interviews with patients complement the medical follow-up, giving the study the unique dimension of patients' personal appraisals of the impact of treatments on their quality of life. Such a rich database makes an invaluable educational reference for MMAF's utilization study groups drawn from the state's physician community. Its numbers provide impartial answers to negative reactions of doctors when told their practices vary from the norm.
Hard data can calm protests
Adjusted data are a calming way to meet the typical protests: "Our patients are sicker, older, or have a backlog of unmet need." (For a glimpse at the types of data analyses and reports MMAF offers physicians, see tables, p. 67.)
The age of the data serves as a convincing reference point regarding which treatments offer the best outcomes over time. Significant changes in decision making and annual cost savings of $6 million to $7 million have come out of MMAF's work.
MMAF learned that its superior research data and physician involvement didn't prevent occasional spikes in utilization and poor patient outcomes. Recently when spine surgeons in Maine noticed such a trend, they approached the MMAF staff and asked for help. MMAF's response evolved into a prototype of essential elements of change in medical practice patterns. But while guidelines and practice data are crucial, they're still only part of the answer.
Headed by orthopedic surgeon and MMAF executive director Robert Keller, MD, the foundation designed a guideline for low back pain treatment options. The material is adapted and condensed from the Rockville, MD-based Agency for Health Care Policy and Research's Guideline #14 Acute Low Back Pain Problems in Adults. (See the resources at the end of this story for details.)
Writing and dispersing the guideline was little more than a good start on the real work of implementation, notes MMAF's associate director Ellen Schneiter, MHSA. "Lots of people are doing guidelines these days," she says, "it doesn't make much impact if you don't follow up." For MMAF, follow-up involves regular presentations at state medical meetings. In other words, she says, "We're in the docs' faces all the time."
Even that isn't enough to effect changes in care practices, however, so MMAF developed a series of slides presenting the guidelines with relevant local data on the outcomes of various back pain treatments. "When they see how their own practice rates compare with the guidelines, that's the catch; it brings it home," Schneiter says. "If they need perspective, we can relate their outcomes to the whole study population."
(For the complete acute low back pain guideline, see p. 68.)
To better weave the guidelines into their everyday routines, Schneiter urges doctors to take a few extra steps, such as tacking them up next to the phone to use when they order X-rays for back pain patients. One doctor wrote himself a pre-X-ray check point excerpted from the guidelines, "Have you waited 30 days?" and taped it next to the phone.
Guidelines are valuable as long as they're noncoercive and physicians use them as just one of their care planning tools. "We stress that they're just something to think about. This is not cookie-cutter medicine," Schneiter points out. "And we're not going to make you lose your license if you don't follow the guidelines."
Keller echoes Schneiter's point about the nonbinding nature of guidelines. In fact, he sees hazards in overly strict adherence. "I keep making the point to the study groups that you can't write a guideline for disk herniation that works in all cases - there are too many shades of gray. If you write the guideline too tightly, some people who could benefit from surgery get left out. If it's too general, all kinds of patients get disk surgery who don't need it, and you don't have good outcomes."
Neurosurgeon and MMAF lumbar study group member, Max Barth, MD, who practices at the Portland office of the Maine Medical Center, believes that guidelines spark useful dialogue between the primary care physicians and specialists. This ultimately leads to better treatment outcomes, he says. "We find ourselves spending a bit more time on the phone with primary care doctors discussing their patients and the appropriateness of surgery or other interventions. Education of the primary care physicians by the specialists is a big part of putting guidelines to their best use because spine surgery is often a judgment; there's no right or wrong choice."
Another value of the guidelines is their patient education function, Keller notes. They help patients understand and wend their way through the gray areas of treatment choices for back pain. He adds that physicians naturally lean toward the methods in which they were trained. For example, a spine surgeon might naturally suggest removal of a herniated disk sooner than would an internist. "We have to provide patients with neutral information for shared decision making. Patients need that information to help filter out the doctor's inevitable bias either for surgical or nonsurgical treatments.
"But two patients with identical symptoms presented with the risks and benefits of both options would choose different treatments. One might say `the risks don't look too bad, and I sure want the benefits of surgery,' and the other might decide to choose watchful waiting to see if the problem goes away with nonsurgical interventions," he explains. Among the other options might be pain relieving medications, rest, and a therapeutic exercise program.
The buffering effect on patient expectations is an additional function of guidelines. "That's where they help the most," adds Dennis Shubert, MD, PhD, chief of surgery at Eastern Maine Medical Center in Bangor, and leader of MMAF's Spine Study Group.
"Patients do affect the decisions a doctor makes." Guidelines help a doctor teach a back pain sufferer why he or she might not need a full battery of diagnostic tests on the first visit or that surgery doesn't cure everything. And because doctors are human, guidelines also ease the pressure they feel when patients press for inappropriate treatments.
Confidentiality key to MMAF success
The best guidelines known to medical science wouldn't make much impact in an environment where the physicians feared public censure for noncompliance. And MMAF credits its success in part to its confidential, educational relationship with the medical community. "We never reveal our doctors' names, and we don't tell on them. That's what brings them to the table," Schneiter says.
In analyses of individual practices, each doctor is identified by a code name. If there are practices that consistently show high utilization or poor patient outcomes, she adds, a group of physicians from the lumbar study group visits them as peers, reviews the guidelines, and discusses the variances between their practice patterns and those of their peers statewide. Even then, no names are singled out.
She explains that recently, several purchasing groups including an employer coalition and the state's Medicaid contractor approached MMAF to discuss quality improvement projects focused on reducing overutilization of diagnostic imaging. "We told them that one condition of our participation is they are not invited when we sit at the table with the physicians to review utilization rates from individual practices. They accept that."
What else does it take to change old habits?
It takes more than guidelines and confidentiality to move physicians away from their familiar habits. While our sources ventured different opinions on what more it might take, they all agreed with Shubert's caveat, "Doctors don't tend to change their practices easily. They do what's worked for them. It's external forces that force change - like if insurance companies say they will no longer pay for a procedure, it makes it impossible because the patients can't afford the service."
The opinions of colleagues are potent influences, Schneiter says. An example is a recent exchange between doctors in one of MMAF's study groups. One doctor routinely ran 20 diagnostic tests on every patient but learned from others who were using outcomes-based guidelines that two or three were enough in most cases. "That doctor reported back to his practice associates, and the group now does two or three tests." Schneiter notes that lessons like those have shown MMAF the value of recruiting respected opinion leaders to serve on projects.
Data is another heavyweight when it comes to persuading physicians, Shubert says. "Good physicians respond to good data because they are, in part, scientists. Unfortunately, there is a lot of pseudo-science out there and outcomes data that aren't sound."
Barth boils it down to a desire to control one's professional practice. "If we don't take charge as doctors," he warns, "then people who don't know as much about our patients as we do will be making decisions for our patients and our practices. That someone else will be the payers or the government."
"I still don't know definitively what would influence every doctor to get involved in reviewing their care practices," he continues. "Some are looking for what's best for their patients. Others never will get involved because they see it as threatening."
References
1. Wennberg J, Gittelsohn A. Small area variations in health care delivery. Science 1973; 182:1,102-1,108.
2. Keller RB. Outcomes research in orthopaedics. J Am Acad Orthop Surg 1993; 1:122-129.
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