Understanding Deviations from Clinical Practice Guidelines in Adult Soft Tissue Sarcoma

In recent years we have witnessed the increasing adoption of clinical practice guidelines (CPGs) as decision support tools that guide medical treatment. As CPGs gain popularity, it has become evident that physicians frequently deviate from CPG recommendations, both erroneously and due to sound medical rationale. In this study we developed a methodology to computationally identify these deviation cases and understand their movitation. This was achieved using an integrated approach consisting of natural language processing, data modeling, and comparison methods to characterize deviations from CPG recommendations for 1431 adult soft tissue sarcoma patients. The results show that 48.9% of patient treatment programs deviate from CPG recommendations, with the largest deviation type being overtreatment, followed by differences in drug treatments. Interestingly, we identified over a dozen potential reasons for these deviations, with those directly related to the patients' cancer status being most abundant. These findings can be used to modify CPGs, increase adherence to CPG recommendations, reduce treatment cost, and potentially impact sarcoma care. Our approach can be applied to additional diseases that are subject to high deviation levels from CPGs

Clinical guideline use and compliance: examining variation from the clinical pathway

Introduction Clinical guidelines are developed with the aim of optimising patient care and have been shown to improve both clinical outcomes and the care process. ‘Hospital HealthPathways’ are guidelines published for use within Canterbury District Health Board (CDHB) hospitals. Previous research into guideline use and compliance in CDHB coined the term ‘appropriate non-compliance’, describing clinically appropriate variation from guideline recommendations. This study used a prospective methodology to observe access of and compliance with the Hospital HealthPathways Community Acquired Pneumonia (CAP) guideline and explore reasons for not accessing or not complying with the guideline. Cases of ‘appropriate non-compliance’ were identified, and a target rate of compliance quantified, taking this into account. Based on findings from the previous research, ‘Practice Points’ – bullet points for emphasis and clarity – were added to acute pancreatitis and CAP guidelines. This study also evaluated the effect of these Practice Points. Findings from the study suggested that the purpose behind a guideline recommendation might influence compliance. A survey was performed to investigate this possibility. Method Demographic data, and data regarding compliance with five key CAP guideline recommendations was collected. Doctors were interviewed regarding their access of and compliance with the guideline. Logistic regression was used to perform subgroup analysis. Demographic data, and data regarding compliance with a ‘Practice Point’ added to the acute pancreatitis guideline was obtained for comparison with data from the previous CDHB research. A survey was designed using a modified three-round Delphi technique to investigate how often doctors thought they should comply with recommendations made for a variety of different reasons, and the comparative importance they placed on the reasons behind the recommendations. Results Usage of the CAP guideline was 38%. Doctors stated they did not access the guideline because they had already made management plans or because they disagreed with the guideline. Both patient and doctor related factors were shown to affect whether guidelines were accessed. Doctor related factors were also shown to affect the reasons for not accessing the guideline. Compliance with four of the guideline recommendations ranged between 67.5-73.5%, however compliance with the recommendation regarding antibiotic choice was lower at 47.5%, leading to poor overall guideline compliance (21.2%). Most doctors did not follow the antibiotic recommendation for objective reasons. Patient and doctor related factors were shown to affect overall guideline compliance. Doctor related factors were also shown to affect the reasons for non-compliance. The target rate of compliance with the antibiotic recommendation, taking into account appropriate non-compliance, was quantified as 62-72%. A significant increase in compliance of 13% was observed with both acute pancreatitis and CAP guideline recommendations following the addition of the Practice Points. In the final round of the survey, a recommendation made for the purpose of preventing short term adverse effects on patients was rated most important. Conclusion The results of this study illustrate the complexity of influences on guideline compliance. The many and varied examples of appropriate non-compliance reflect the case-by-case reprioritisation of the facets of patient care by clinicians, despite the continued proliferation of clinical guidance. Studies such as this can enhance understanding of how doctors use clinical judgement to respond to scenarios they feel outlie the guidelines. Improving guidelines to better reflect how they are used by clinicians could in turn increase guideline compliance