Association of Community Cancer Centers
In a field as rapidly changing as oncology, clinical practice guidelines (CPGs) are an important resource for providers using evidence-based medicine. In fact, with recent encouragement by the federal government, private insurers and specialty societies, the use of CPGs is expected to grow substantially. Still, evidence suggests that adherence to practice guidelines in the community oncology setting is uneven (Smith TJ, Hillner BE. Ensuring quality cancer care by the use of clinical practice guidelines and critical pathways. J Clin Onc. 2001; 19(11):2886-2897).
In March 2010 the Association of Community Cancer Centers (ACCC) proposed a unique needs assessment to address the use of CPGs in the community oncology setting. ACCC appointed an expert advisory panel to help guide this project in collaboration with Avalere Health, a leading healthcare consulting company. We identified 50 programs that use CPGs and developed a survey that a medical oncologist, oncology nurse, and oncology pharmacist at each program were asked to take. Survey results were tabulated and analyzed, with the intent to find solutions to inconsistencies in CPG usage and understand differences within institutions and across disciplines.
With its multidisciplinary membership, ACCC is uniquely positioned to gain insight into the use of CPGs across disciplines in the community setting.
Through this study, ACCC has taken a critical step toward understanding community oncology practices' use of and adherence to CPGs.
Five Key Findings
Respondents indicate that nearly all physicians refer to CPGs, and follow their recommendations most of the time. Physician, nurse, and pharmacist respondents all report that physicians adhere to guidelines over 80 percent of the time. The majority of respondents believe that guidelines are credible, easy to follow, lead to better patient outcomes, and serve an important role in ensuring high quality care. Respondents report minimal internal conflict within the cancer program or group practice over which guidelines to use and physicians are widely considered the final arbiter of CPG use.
Physicians report that they refer to the National Comprehensive Cancer Network's guidelines most often, followed by the American Society of Clinical Oncology's guidelines. The most commonly reported ways by which physicians access CPGs are through online guidelines and online medical journals. The most popular format for CPGs among all providers is algorithm, which is arguably the quickest way to access the information.
In spite of positive attitudes about CPGs overall, respondents cite many barriers to using guidelines consistently, effectively, and efficiently in the healthcare setting. These include: Guidelines are too rigid or not appropriate for the unique clinical situation; guidelines are difficult to locate or implement; physicians do not have enough time to refer to guidelines; and guidelines require a significant change of practice.
A key to reducing these barriers is making them more easily accessible. The study noted that the most common way for physicians to access guidelines is online, either through medical journals or guideline statements. Many physicians report, however, that health information technology (HIT) tools, such as customized electronic medical records and clinical decision support modules, would make it easier to provide evidence-based care. Nonetheless, few respondents have these tools currently in place.
Nurses and physicians tend to disagree over the frequency with which physicians implement CPGs and whether physicians document the reason they choose not to follow CPGs.
Within a cancer program or group practice, the attitudes across the physician, nurse, and pharmacist are highly consistent, suggesting that culture may lead to agreement on the utility of guidelines and their positive impact on patient care. However, physicians and nurses disagree on the frequency with which physicians implement guidelines in clinical practice. Nurses are almost as likely to overestimate as they are to underestimate physician adherence to CPGs, when compared to their corresponding physicians' responses.
Nurses and physicians tend to disagree over whether physicians document the reason they choose not to follow CPGs. To a lesser extent, there is disagreement over whether physicians document their use of guidelines. Again, when compared to their corresponding physician’s responses, nurses both overestimate and underestimate documentation.
Programs and practices engage in their own guideline development, and these activities are not greatly influenced by payer guidelines or performance measurement. Nearly all programs and practices have at one point created their own guidelines, with a quarter of respondents creating them often or always. Programs and practices are more likely to generate guidelines for breast, lung and GI cancers.
Many practitioners report that they believe that CPG adherence affects physician reimbursement; however, they do not appear to see performance measurement as the link between adherence and reimbursement. When asked specifically about pay-for-performance (P4P), some do report that P4P programs are encouraging physician guideline adherence. However, 22 percent of physicians believe that payers do not encourage adherence to guidelines. Respondents report some uncertainty over whether their programs or practices are using CPG adherence internally to assess performance, though this is more commonly reported by nurses and pharmacists.