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TRH 01-031 – HSR Study

TRH 01-031
A Custom Approach to Implementation of Diabetes Hypertension Guidelines
Julie C. Lowery, PhD MHSA
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Sarah Krein PhD RN
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Funding Period: July 2001 - September 2004
Although educational strategies are the approach most often favored for translating research findings into practice, education alone seldom results in lasting practice changes. In addition, even though many translation (change) strategies have been found to work some of the time, none works all of the time.

The project we propose is based on a new perspective on changing physician practices, which provides a guide for selecting the most effective change strategies for a given group of physicians. A central feature of the new framework is the classification of clinicians into four categories based on their usual responses to new research findings about the effectiveness of clinical practices. For each category of clinician the framework specifies which change strategies are most likely to be effective. The objective of this 1 year observational study is to evaluate the construct validity and reliability of the instrument for classifying physicians into the four categories.

The study will include a combination of retrospective, cross-sectional, and prospective analyses and will test the following hypotheses:
(1) Retrospective longitudinal analysis (for evaluating construct validity): Change over time in compliance with diabetic hypertension guidelines will vary by physician type and guideline implementation strategy. Guideline compliance for this hypothesis will be measured by the change in percentage of hypertensive diabetic patients with a prescription for a beta blocker, ACE inhibitor, or thiazide diuretic.
(2) Cross-sectional analysis (for evaluating construct validity): The intermediate outcome (blood pressure) of treatment of hypertensive diabetic patients will vary by physician type and guideline implementation strategy.
(3) Prospective analysis (for evaluating reliability): There is no significant difference in responses to the physician classification instrument obtained approximately 12 months apart.
During the first 12 months of year 1 of the study, semi-structured telephone interviews were conducted with two of the following individuals at a sample of 43 VAMCs: Chiefs of Staff, Associate Chiefs of Staff for Ambulatory Care, Quality Managers, attending physicians, or Directors of Primary Care. The purpose of these interviews was to determine what strategies have been implemented for meeting diabetes hypertension guidelines-specifically in the time period from 1999 through 2001. Following human studies approval, all primary care physicians in these same VAMCs will be sent a copy of the physician instrument to complete, and again one year later. In addition, data on these physicians' diabetic outpatients, their hypertension prescriptions, blood pressures, and primary care providers will be obtained from national data sets and VISTA. These data will be collected for the first six months of FY 1999 (considered pre-guideline implementation) and for the second six months of FY 2001 (the most recent time period for which we have these data, and considered post-guideline implementation).

Results from the interviews showed that all of the participating sites used some type of educational approach to implement the guidelines, whether written, a presentation, or a conference. Over 90% of the sites also provided group or individual feedback on physician performance on the guidelines, and over 75% implemented some type of reminder system. A minority of sites used monetary incentives, penalties, or analysis of barriers. Of 747 questionnaires distributed to primary care physicians, 304 were returned (response rate of 40.7%). According to our physician classification system, 63.7% of the participating physicians are "pragmatists"; 24.6% are "receptives"; 11.4% are "seekers"; and 0.3% are "traditionalists".

A valid physician classification instrument can be used by clinicians and managers, both within and outside VHA, to tailor the design of their research translation or guideline implementation efforts to the types of physicians in their organizations, thereby improving the effectiveness of their efforts.

External Links for this Project

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Journal Articles

  1. Green LA, Wyszewianski L, Lowery JC, Kowalski CP, Krein SL. An observational study of the effectiveness of practice guideline implementation strategies examined according to physicians' cognitive styles. Implementation science : IS. 2007 Dec 1; 2:41. [view]
  2. Green LA, Lowery JC, Kowalski CP, Wyszewianski L. Impact of institutional review board practice variation on observational health services research. Health services research. 2006 Feb 1; 41(1):214-30. [view]

  1. Kowalski CP, Wyszewianski L, Lowery J, Krein S, Green LA. VA Diabetes Hypertension Guideline Implementation Strategies: Qualitative Interview Summary Report. 2003 Mar 27. [view]
Conference Presentations

  1. Green LA, Kowalski CP, Krein SL, Lowery JC, Wyszewianski L. Effect of physician information style and implementation strategy on guideline adherence. Poster session presented at: Society for Medical Decision Making Annual Meeting; 2005 Oct 1; San Francisco, CA. [view]
  2. Lowery JC, Krein SL, Green LA, Wyszewianski L, Kim HM, Kowalski CP. Factors affecting compliance with diabetes hypertension guidelines. Paper presented at: AcademyHealth Annual Research Meeting; 2006 Jun 25; Seattle, WA. [view]
  3. Kowalski CP, Lowery J, Wyszewianski L, Green L. VA diabetes hypertension guideline implementation strategies. Paper presented at: VA HSR&D National Meeting; 2003 Feb 12; Washington, DC. [view]

DRA: Health Systems
DRE: none
Keywords: Clinical practice guidelines, Diabetes, Translation
MeSH Terms: none

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