Most upper respiratory illnesses (colds, sinus infections and acute bronchitis) are caused by viruses. Typical antibiotics will not be helpful in curing these infections. In fact, overuse of antibiotics leads to bacterial resistance, a situation in which antibiotics lose their ability to kill bacteria. Antibiotic resistant infections have been estimated to cause 23,000 deaths annually.
To improve this situation, guidelines have been published around inappropriate antibiotic use. But as a nation, the US is not complying with these guidelines. A recent report from the NCQA showed that compliance with these guidelines has decreased, falling from 29% in 2009 to 24% in 2012. The report did show improvement in levels of compliance with guidelines for childhood obesity screening and pediatric immunizations.
Why do physicians follow guidelines at such a low level? There are several reasons:
- Some guidelines are overly complex – LDL cholesterol -lowering guidelines come to mind.
- In the example of antibiotics, some physicians don’t have the time to ‘negotiate’ with patients about the advisability of antibiotics in certain situations.
- Physicians have an incentive to keep patient satisfaction scores high, which may lead to ordering tests or treatments because patients want them, even if not needed.
- Clinical situations exist where guidelines do not apply.
As a nation, are we doing any better with other screening recommendations? Nation-wide, breast cancer screening rates (as of 2010) are 72%, cervical cancer screening rates are 83% and colon cancer screening rates are only 59% of those who are eligible.
It is hoped that changes in the Affordable Care Act (ACA) to cover these screening procedures with no out of pocket charges will improve compliance with the guidelines. But we cannot expect 100% coverage to solve the problem. Many employers have offered these services at 100% coverage for some time, and yet their employees’ screening rates are often quite low.
There are several reasons for non-compliance with screening recommendations:
Fear of learning one has cancer
- Lack of knowledge about the test.
- Fear of the test causing pain or discomfort.
- Perception of cost.
- Not wanting to take the time to have the test.
- No personal primary care physician.
- Personal physician neglected to recommend the test.
- Perception that guidelines change often and may not be correct, as has been the case with breast and cervical cancer screening.
To improve compliance with guidelines, each of these factors should be considered. Educational materials need to be personalized and as specific as possible, and information about price transparency is a must.
Guidelines and templates for clinical care have the potential to improve the quality of medical care delivered, and better implementation of guidelines requires both patient and physician education and acceptance.
Michael L. Taylor, MD FACP
Chief Medical Officer