- Lack of information. Sometimes, the information either doesn’t get to physicians or isn’t absorbed. This is especially true outside the otolaryngology specialty.
- The “recency” effect. If a physician has had a recent bad experience with a patient despite following practice recommended in a guideline, he or she may be less inclined to follow the guideline later.
- Patient resistance. Even when presented with the reasons a certain treatment strategy is not appropriate, a patient might insist on that strategy anyway.
- Insurance barriers. Sometimes insurance might resist paying for or decline to pay for care recommended in a guideline, such as imaging in a timely manner.
- Access to medication. A medication shortage could make it difficult for physicians to access the medications recommended by a guideline.
- Willingness or ability to pay. Sometimes, a patient might not want to pay the out-of-pocket amount that’s required to move forward with care recommended by a guideline.
- Slow adopters. With any innovation, there will be some people who are slow to change, even if they are aware of the evidence and the recommendation.
Making Guidelines More Widely Available
Dr. Tunkel said that the AAO-HNS makes an effort to give lectures on guidelines at meetings, makes slide shows available on its website, and involves other disciplines in the development of guidelines so that they are as comprehensive and as widely relevant as possible. But there is still work to do to disseminate the information.
“I think guidelines, in and of themselves, published in a medical journal is probably not a very good way of encouraging adherence or acceptance of a guideline. We need to incorporate [them] into clever ways of implementing things,” Dr. Tunkel said. “There’s still a group of physicians who don’t know about guidelines when they get published. And so the Academy tries to do that with the website. They also try to involve as many people as they can into the development of guidelines.” For instance, with the AAO-HNS tinnitus guidelines, hundreds of suggestions were made during the peer review and public comment period, which led to improvement of the guidelines, he said.
Jeremy Meier, MD, assistant professor of surgery in the division of otolaryngology-head and neck surgery at the University of Utah School of Medicine in Salt Lake City, whose research has found that many surgeons still routinely give antibiotics for tonsillectomy despite a guideline recommending against that practice, said physicians need to be made aware of their outcomes and guideline adherence. “Surgeons need to know their own data and their own outcomes,” he said. “Anecdotally, they may think that they’re providing the best practice, but if they truly were to go back and look at their outcomes, they may see that giving the antibiotics or not really didn’t make a difference.”