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A survey of attitudes to clinical practice guidelines in general and adherence of the Korea practical guidelines for management of gallbladder polyp: a survey among private clinicians in Korea
Korean J Hepatobiliary Pancreat Surg 2014 May;18(2):52-5
Published online May 31, 2014
Copyright © 2014 Korean Association of Hepato-Biliary-Pancreatic Surgery.

Jooyeon Jeong, Jae Keun Kim, Joon Seong Park, and Dong Sup Yoon

Pancreatobiliary Cancer Clinic, Department of Surgery, Gangnam Severance Hospital, Yonsei University Health System, Seoul, Korea
Received February 16, 2014; Revised May 15, 2014; Accepted May 18, 2014.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
 Abstract

Backgrounds/Aims

While clinical practice guidelines are effective tools for improving the quality of patient care and provide specific recommendations for daily practice, the usage of them have been often suboptimal. Therefore, evaluation of physician attitude to guidelines is an important initial step in improving guideline adherence levels. The aim of this study was to survey the attitude on general guidelines and adherence with the Korea Practical Guidelines for gallbladder (GB) polyp two year after their publication and distribution among Korean private clinicians.

Methods

To evaluate the survey, questionnaires were sent with a stamp on an addressed envelope to 3,256 private clinicians who were registered at the Seoul Medical Association in April, 2010. From the 3,256 questionnaires, 376 clinicians (11.5%) responded to the survey.

Results

A total of 91.0% responders agreed to the statement that general guidelines were useful tools for improving patient care and quality of care. One hundred one responders (26.9%) stated that they were aware of the Korea GB polyp guidelines while 73 physicians (72.3%) founded the guideline had changed their practice and user-friendly. Most of physicians (73.4%) agreed to practical procedures recommended by guidelines.

Conclusions

Korean primary physicians were generally positive to the practical guidelines, as propagation of the guideline among primary physicians may improve adherence to guideline and patients care for GB polyps.

Keywords : Attitude; Adherence; Guidelines; Survey; Gallbladder polyp
INTRODUCTION

Clinical guidelines were developed to improve quality of patient care, standardize clinical practice, and possibly reduce costs.1,2 However, many studies have shown that guidelines were still not being adequately implemented in actual clinical practices.3,4,5 Although many factors may influence the implementation of guidelines in practices, the evaluation of the physician's attitude to guidelines is an important initial step in improving guideline adherence.

The prevalence of GB polyp was reported around 5% of the total population in Korea, and general practitioners frequently face it.6 Clinicians have some difficulties in making decisions in management and treatment strategies for GB polyp, because it has been frequently reported to be difficult to differentiate malignant lesions by imaging modalities. Therefore, evidence-based standardization of diagnostic and therapeutic options has been needed to improve the quality care of patients. For that purpose, in 2010, Korean Association of Hepatobiliary and Pancreas Surgery (KHPBA) released the Korea Practical Guidelines for Management of Gallbladder (GB) polyp.7

In Korea, there has been little or no study about the attitudes of primary physicians on general guidelines. This study, therefore, is aimed to investigate primary clinicians' attitude on general guidelines and adherence with the Korea Practical Guidelines for management of GB polyp two year after their publication and distribution.

MATERIALS AND METHODS

To evaluate the survey, anonymized questionnaires were sent with a stamped addressed envelope to 3,256 private-practice clinicians (internal medicine, general surgeon and family medicine) who were registered at the Seoul Medical Association in April, 2010. Academic institutions or hospitals were excluded.

The questionnaire had 16-item questions and consisted of three sections; general sections, guideline specific parts, and question concerning the gallbladder polyp practical guidelines.2 The general section included questions about demographics and professional characteristics such as age, specialty and years in practice. The guideline specific section consisted of statements on attitude to general guidelines. Attitude assessments were based on the questionnaire developed by Kunz.8 The GB polyp guidelines questions were focused on diagnosis, treatment, and acceptance of current Korea Practical of GB polyp guidelines.

Statistical analysis

Frequencies of different answers to each question on the survey were calculated. Data was left out only on low frequencies, thus sample sizes varied slightly from question to question. Further detailed statistical analysis was not performed on the survey data because this study aimed to provide an overall frequency of questions.

RESULTS
Survey response and physician characteristics

A total of 376 clinicians responded to the survey, resulting in a response rate of 11.5% (376 of 3256). The general characteristics of the responders are listed in Table 1. The majority of responders were male (83.8%), most were aged between 50 and 59 years (43.4%), having internal medicine specialty (75.8%), and worked in solo practices (89.6%).

General attitude toward guidelines

The responders reported positive attitudes to guidelines (Table 2). A majority of responders (91.0%) agreed to the statement that general guidelines are useful tools for improved patient care and quality of care. A small proportion of responders (15.2%) were concerned that guidelines interfered with the physician autonomy.

Attitude and adherence on Korean GB polyp guidelines

One hundred one responders (26.9%) stated that they were aware of the GB polyp guidelines. Among these 101 clinicians, 73 clinicians (72.3%) founded the guideline had changed their practice and user-friendly.

To know adherence between GB polyp guidelines and actual practice by clinicians, a list of 8 medical situations was selected. Participants were asked to specify how often they were consistent between GB polyp guidelines and actual practice. Eight different clinical situations and answers were presented in Table 3.

Most of physicians (73.4%) always agreed that abdominal ultrasonography is routine diagnostic tool as recommended by the guidelines.

Physicians were asked whether they would recommend the prophylactic operation in high-risk patients. Most of physicians agreed to operate GB polyps categorized as high-risk according to the KHPBA guideline, but only 10.6% of responders agreed to recommending operation for single GB polyp.

DISCUSSION

Clinical practice guidelines are effective tools for improving the quality of patient care by providing specific recommendations for daily practice. However, most attention has been focused on developing guidelines rather than on their practical implementation. This study was the initial surveillance of the attitudes to general guidelines and the Korea Practical Guidelines for Management of GB polyp among Korean primary clinicians. In this study, the response rate was low when it compared the previous similar studies to the response rates between 20% and 30%.9,10 This low response rate may be explained by the lack of interest in this survey. While many studies offered continuing medical education accreditation point for completing the questionnaire, this survey did not.

Korean primary clinicians in this study had a positive attitude towards the general guidelines. Particularly, only 15% of responders believed that general guidelines reduce a physician's autonomy and this rate was on the lower when compared to other studies.8,11 This positive attitude to the guidelines may be related to a strong sense of ownership as most guidelines were developed by Association Committees and their guidelines were presented as 'guidelines for doctors developed by doctors.

In this study, 26.9% of responders stated that they were aware of the GB polyp guidelines but this result was low when compared to other studies.9,12 The low rate of awareness of GB guidelines may be explained by the current study enrolled private primary clinicians rather than the specialists, because it has been known that specialists were more familiar with guidelines pertaining to their own subspecialty than to general medical practices.9,12 Thus, to disseminate the clinical guidelines and maximize their usages, the organizations that develop clinical guidelines have to make efforts to propagate them in associating private primary clinicians or providing some benefits such as offering continuing medical education accreditation points.

The majority of the participated primary care clinicians agreed to the KHPBA GB polyp guidelines and used them in actual clinical practices. This result may imply that current GB polyp guidelines provide concise recommendations and formatted user-friendly. However, because of low response rates of surveys among physicians, there is a limitation to generalization of current findings. Second, because of this study is based on questionnaires rather than clinical objective parameter, the responses are a written scenario and the decision taken when confronted with an individual patient in the real world varies.

In conclusions, Most of Korean primary physicians has positive attitude to the general guidelines and KHPBA GB polyp guidelines. The results of this study showed that propagation and dissemination of guidelines had the major role in clinical usage of the guidelines. Therefore propagation of the guideline among primary physicians may improve adherence to guideline and patients care for GB polyps, however further studies are needed to assess effective guideline implementation strategies.

Tables

Demographic and professional characteristics of the responding doctors





Responders' attitude to general guidelines





Adherence between Korea Practical Guidelines for management for GB polyp and actual practice by primary-care physicians




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