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Examining the Influence of Clinician Decision Making on Adherence to a Clinical Guideline

Dr. Falzer is affiliated with the Clinical Epidemiology Research Center, Department of Veterans Affairs Connecticut Healthcare System, 950 Campbell Ave., Building 35A, Mailcode 151B, West Haven, CT 06516 (e-mail: paul.falzer{at}yale.edu). Ms. Garman is with the Southwest Connecticut Mental Health System, State of Connecticut Department of Mental Health and Addiction Services, Bridgeport. Dr. Moore is with the Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut.

OBJECTIVE: Reluctance to follow treatment guidelines was illustrated previously by a study in this journal that found a 5% endorsement rate for a medication-switching algorithm for treatment-resistant schizophrenia. The study presented here attempted to account for this low rate by using clinical vignettes to manipulate key factors. METHODS: Twenty-one psychiatric residents responded to 64 vignettes. Expected progress and patient adherence to treatment were systematically manipulated within the vignettes, because they were most responsible for clinician decisions. Endorsement was analyzed using a fully crossed 4 x 2 within-subjects design. RESULTS: When expected progress and patient adherence were factored in, mean endorsement ranged from 5% to 87%. Adding guideline variables (short-term progress assessment, current condition, and guideline step) expanded the endorsement range from 1% to 90%. CONCLUSIONS: The low endorsement rate found previously is explained principally by the patient's expected progress. The brief report concludes by discussing ways to promote implementation when expected progress is only moderate.

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