Why Do Physicians Not Follow Evidence-Based Guidelines for Preventing Ventilator-Associated Pneumonia?: A Survey Based on the Opinions of an International Panel of Intensivists

doi:10.1378/chest.122.2.656

Chest

Volume 122, Issue 2, August 2002, Pages 656-661

https://doi.org/10.1378/chest.122.2.656 Get rights and content

Objective

Adherence to clinical practice guidelines is highly variable. Our objective was to review barriers to physicians' adherence to evidence-based guidelines (EBGs) for preventing ventilator-associated pneumonia (VAP).

Methods

A questionnaire was administered to 110 opinion leaders on VAP from 22 countries to indicate whether 33 pharmacologic and nonpharmacologic practices that had been listed in a recent publication had been implemented in their ICUs. If these prevention strategies were not used, the respondents were asked to indicate one of seven reasons for nonadherence, with the objective of identifying barriers to adherence to EBGs.

Results

The overall nonadherence rate was 37.0%. The nonadherence rate was 25.2% for strategies recommended for clinical use, compared with 45.6% for strategies with less effectiveness (odds ratio [OR], 1.80). Pharmacologic strategies had a higher degree of nonadherence than nonpharmacologic strategies (OR, 2.92). Nonadherence to recommendations graded A, B, C, D, and U based on an objective assessment of the consistency of the supporting evidence was 41.3%, 35.7%, 16.0%, 45.7%, and 20.8%, respectively. The most common reasons for nonadherence were the following: disagreement with interpretation of clinical trials (35%); unavailability of resources (31.3%); and costs (16.9%).

Conclusion

We conclude that nonadherence to EBGs for preventing VAP was common and largely uninfluenced by the degree of evidence. A rational approach toward improving VAP guideline adherence should take into account the heterogeneous factors that influence physician adherence to them.

Section snippets

Materials and Methods

We prepared a questionnaire that assessed 33 potential strategies for preventing VAP. The interventions examined on the questionnaire and the recommendation for clinical use (ie, effective, ineffective, or strategies of equivocal or undetermined effectiveness) were taken directly from the review article by Kollef.⁵ The items listed in Tables 3 are taken directly from this publication.

We asked all physicians who had previously been selected and invited to attend an international symposium on

Results

The survey was answered by 62 of the 110 physicians (56.4%) who were approached. Their countries of origin are shown in Table 1. Overall, 54.8% of responders were from member countries of the European Union. Other European countries represented 30.6% of responders, and 8% of responders were from South America. Russia was represented by four physicians, the Middle Orient was represented by two physicians, South Africa was represented by one physician, and North America by one physician. Their

Discussion

Little is known about barriers to physicians' adherence to clinical practice guidelines. There is very scarce information, to our knowledge, to assess why physicians may not follow EBGs for preventing VAP. We assessed six potential barriers and found the most important to be disagreement with the interpretation of reported trials and lack of resources. In contrast, potential patient discomfort, adverse effects, and convenience for nursing staff were rarely mentioned.

In 2000, a Franco-Canadian

ACKNOWLEDGMENT

We are indebted to Montse Olona, MD, for statistical and methodological advice.

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: This study was supported by Comisio Interdepartamental de Recerca i Innovació Technologica (grant No. 2000-SGR-128) and Distinció per la Promoció de la Recerca Universitaria.

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Chest

Clinical Investigations in Critical CareWhy Do Physicians Not Follow Evidence-Based Guidelines for Preventing Ventilator-Associated Pneumonia?: A Survey Based on the Opinions of an International Panel of Intensivists

Objective

Methods

Results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

ACKNOWLEDGMENT

Lancet

Understanding physicians adherence with a pneumonia practice guideline

Arch Intern Med

Why don’t physicians follow clinical practice guidelines?

JAMA

The effect of clinical practice guidelines on variations in care

Ann Intern Med

Influence of airway management on ventilator-associated pneumonia

JAMA

The prevention of ventilator-associated pneumonia

N Engl J Med

Ventilator circuit and secretion management strategies: a Franco-Canadian survey

Crit Care Med

Compliance with handwashing in a teaching hospital: Infection Control Program

Ann Intern Med

Reasons for noncompliance with infection control guidelines

Infect Control Hosp Epidemiol

Why don’t doctors and nurses wash their hands?

Infect Control Hosp Epidemiol

Clinical Investigations in Critical Care
Why Do Physicians Not Follow Evidence-Based Guidelines for Preventing Ventilator-Associated Pneumonia?: A Survey Based on the Opinions of an International Panel of Intensivists