Academic Psychiatry 23:9-13, March 1999
© 1999 Academic Psychiatry
APA Practice Guidelines
A Pilot Study of a District Branch-Based Educational Intervention: Awareness and Reactions
Steven L. Jaffe, M.D. and
Joel Yager, M.D.
Dr. Jaffe is Professor of Psychiatry, Emory University School of Medicine, and Clinical Professor of Psychiatry, Morehouse School of Medicine, Atlanta, Georgia. Dr. Yager is Professor and Vice Chair, Department of Psychiatry, University of New Mexico School of Medicine, Albuquerque. Address correspondence and reprint requests to Dr. Jaffe, 6667 Vernon Woods Drive, #B-20, Atlanta, GA 30328-3282.
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ABSTRACT
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Seventy-eight psychiatrists attending an American Psychiatric Association (APA) district branch continuing education meeting were surveyed about their awareness and acceptance of the APA's practice guideline for bipolar disorder. Assessments were conducted immediately before and again immediately following an educational intervention, which consisted of a 3-hour slide-show and lecture presentation on these guidelines. Before the presentation, one out of six of these psychiatrists did not know that practice guidelines even existed, and about one-half did not have (or did not know that they had) a copy, and they did not know that guidelines were published in the American Journal of Psychiatry. Almost half had not read any of the bipolar guideline, whereas 34% had read "some" or "thoroughly." Responses before and following the intervention showed that a large majority of the psychiatrists felt that this specific guideline generally validated the manner in which they treated patients with bipolar disorders, and almost half felt that knowledge obtained from the guideline had changed, or would change, their treatment of bipolar disorders in the future. High levels of acceptability for the guideline were reported both by those who had previously read the guideline and those who first became familiar with it during the presentation. Presentations at APA district branches may aid in dissemination of practice guidelines, but additional interventions and dissemination techniques are required as well. Since questions based on the APA's practice guidelines will be increasingly influential in American Board of Psychiatry and Neurology recertification examinations, more comprehensive dissemination methods are needed to assure that practitioners are well acquainted with these guidelines.
Key Words: Practice Guidelines • Bipolar Disorder • Educational Intervention
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INTRODUCTION
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During the past several years, the American Psychiatric Association (APA) has been developing, writing, and publishing guidelines for the assessment and treatment of a number of psychiatric disorders (1). Those already published include guidelines for eating disorders, major depressive disorder, bipolar disorder, substance use disorders and psychiatric evaluation of adults, nicotine dependence among psychiatric patients, and schizophrenia. Several more APA guidelines are in various stages of development. Although the first guideline was published in the American Journal of Psychiatry in 1993, to our knowledge, no past studies have been conducted on awareness and acceptability of the guidelines by practicing psychiatrists. We present the results of a pilot survey and intervention conducted at the winter (February 1996) scientific meeting of the Georgia Psychiatric Physician's Association, the APA's Georgia district branch.
The scientific program for the district branch meeting focused on the APA's practice guideline for bipolar disorder (2). At the start of the meeting, before the educational presentation, a preprogram survey instrument was distributed and "preintervention" questions were completed by the audience members. A 3-hour lecture and slide-show presentation (the educational intervention) on the bipolar disorder practice guideline was then given by one of the members of the work group that developed these guidelines (Paula Clayton, M.D.). The presentation included discussions of the background and history of guideline development, as well as the specifics of assessment and treatment of bipolar disorders, according to the practice guideline. Following this educational program, a set of "postintervention" questions were answered. The survey instruments appear in the Appendix.
For those who had previously read the bipolar disorder practice guideline before the educational intervention, we surveyed the extent to which the guideline validated how the psychiatrists were already treating these patients and whether the guidelines changed how they treated these patients. These questions constituted our measures of "reactions." At the end of the lecture, all participants were asked the same questions about reactions.
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RESULTS
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Demographics
The seventy-six members of the Georgia Psychiatric Physician's Association who attended the first part of the winter 1996 scientific program participated in this study. Their average age was 52 years (range: 27 to 82). Seventy-two percent were male, and 28% were female. Fifty-nine percent practiced in urban and 25% in suburban communities. The number of years in practice was fairly evenly distributed, with roughly 10% of the group having practiced for each of 10 five-year groups (covering 0–50 years of practice). Most (62%) treated patients more than 30 hours per week. Sixty-eight percent were in full-time private practice, while 24% were in almost full-time public practice.
Preintervention Survey
Sixteen percent did not know that practice guidelines existed. One-half knew that they had a copy of the bipolar guideline, and half responded that they did not have a copy. Forty-five percent did not know that practice guidelines were published in and distributed in the American Journal of Psychiatry. Forty-seven percent had read "none" of the bipolar guideline, whereas 34% had read a significant amount ("some" to "thoroughly"). None of the responses varied significantly by years in practice, with the exception that all respondents who had been in practice between 36 and 40 years indicated that they were unaware that the guidelines were published in the American Journal of Psychiatry. None of the responses in the pre- or postintervention survey varied significantly by gender, practice location, or hours per week of practice.
Thirty-five participants responded to the preintervention survey questions addressed to those who had previously read the bipolar guideline. Of these, 83% agreed significantly with the contents of the bipolar guideline. Eighty-six percent indicated that the guideline validated how they had already been treating bipolar patients. Forty-six percent indicated that reading the bipolar guideline had affected their treatment of these patients, leading the respondents to add to or change their treatment "some" to "a lot." Written comments suggest that the responses on validation and stimulation to add or change practice centered on issues of medication strategies, particularly the use of lithium (which most were doing), and considerations of newer thymoleptics (for the adding to or changing their practice regimen).
Postintervention Survey
After the 3-hour lecture and slide-show presentation, the 78 psychiatrists in attendance completed the postpresentation survey. Sixty-six percent indicated they had learned something new ("some" to "a lot"). Ninety-six percent indicated the bipolar guideline validated how they clinically practice. Written comments as well as comments and discussion at the meeting indicated that the sense of validation primarily revolved around the practitioners' medication strategies (e.g., on the workup for and use of lithium). Forty-nine percent responded that the educational intervention would add to or change how they thought they would later treat bipolar patients significantly ("some" to "a lot"). Again, written and verbal comments on what the psychiatrists might add or change primarily concerned medication strategies (e.g., using valproic acid for bipolar disorder). Again, the responses were unrelated to the respondents' years in practice.
In response to the question about how APA might best help members read and use the practice guideline, specifically which of the following activities the practitioner would "like to see and would support," 73% endorsed articles about the guidelines in Psychiatric News, 70% endorsed continuing medical education (CME) courses given by expert consultants, 23% endorsed weekly or monthly case-based peer-supervision groups, and 29% endorsed Internet bulletin-board–based educational activities on the guidelines.
Additional suggestions written in by the participants included 1) having periodic supplements in the American Journal of Psychiatry focusing on a specific clinical problem; 2) using the guidelines as a basis for treatment; 3) publishing the guidelines with better visual aids, good visual illustrations, and sidebars, with expert commentary; 4) offering guideline-related CME courses on videotape and audiotape; 5) offering guideline-related CME by mail or journal; 6) offering monthly case-based peer-supervision groups on the Internet; and 7) encouraging departments of psychiatry at local medical schools to offer CME-related presentations and courses based on the use of guidelines for assessment and treatment.
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DISCUSSION
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This report presents 1) the first survey of practicing psychiatrists at an APA district branch CME meeting about their awareness of and reactions to a published APA practice guideline and 2) the first attempt to assess the potential impact of a structured educational intervention focusing on one specific guideline, the guideline for bipolar disorders. While many methodological limitations to this pilot study are obvious (e.g., the small, potentially nonrepresentative sample, the previously untested survey instrument), interesting and suggestive preliminary information was obtained as to the degree of awareness of the guideline (effectiveness of dissemination), reactions to the bipolar disorder guideline among those who were aware of its existence and who had previously read them to at least some extent, and suggestions for better dissemination of guidelines. Given that one out of six of these psychiatrists did not know that practice guidelines even existed, about one-half did not have (or did not know that they had) a copy and did not know that the guidelines were published in the American Journal of Psychiatry, and that half had not read any of the APA guideline on bipolar disorder, the need for more dissemination to promote wider awareness and actual study of the guidelines by practitioners is obvious.
Those who had already read the bipolar guideline showed a high rate of acceptance, with 83% agreeing with the guideline and 86% indicating that the guideline validated their treatment of these patients (or at least major aspects). These responses may indicate that most of these psychiatrists were aware of and were already using sound contemporary methods and proper guidelines for the treatment of their bipolar patients and/or that to a large extent the authors of the APA practice guidelines accurately described the manner in which most psychiatrists approach these treatment problems.
After the educational intervention, reactions to the bipolar guideline were quite positive, with 96% of the psychiatrists indicating that this guideline validated how they treated their patients, in addition to which two-thirds indicated they learned something new, and almost half stated that the presentation of the guideline would add to or change how they treated bipolar disorder patients. Following the educational intervention, the percentage reporting that the guideline validated how they practice was higher than among those initially responding to the impact of previously reading the guideline. The lecture and slide-show presentation may have resulted in greater impact and more positive reactions than reading, or this response rate may reflect a "recency" effect, due to the assessment having been conducted immediately after the presentation. The fact that the presentation was made by a well-known authority, Dr. Clayton, may have added to the intervention's value, and to the positive response. This likelihood is consistent with research showing that opinion leader-based education was a more effective dissemination strategy for a practice guideline on the management of women with previous cesarean sections than simple medical-record audit and feedback (3).
Although the current pilot study lacks a comparison group of practitioners who did not participate in the Georgia Psychiatric Association conference to assess the responses of psychiatrists not potentially biased by the presence of an authority or the context of responding at a meeting, our findings can be compared with the results of an unpublished APA survey of 910 psychiatrists that dealt with, among other issues, practice guidelines (APA Office of Research, 1996). Forty-seven percent of our respondents and 38% of the APA survey respondents reported that they had not read the guidelines. Eighty-six percent of our respondents felt that the bipolar guideline validated aspects of their practices, and 46% said that the guideline added to or changed how they would practice (largely concerning specifics of prescribing medications), whereas 90% of the APA survey respondents reported that they found the guidelines "helpful." These figures are similar to those found among internists in the research done by the American College of Physicians (ACP) (4). Among a group of about 1,500 respondents to a survey of ACP members, familiarity with guidelines varied from 11% for the ACP guideline on exercise treadmill testing to 59% for the National Cholesterol Education Program Guideline. Among the respondents, 70% thought that guidelines would improve the quality of health care. Of note, several negative opinions about the guidelines were also noted: 43% thought guidelines would increase health care costs, 68% believed they would be used to discipline physicians, and 34% thought the guidelines would make practice less satisfying.
Although our pilot project suggests that presentations at APA district branch meetings might be an effective vehicle for dissemination of practice guidelines, a follow-up survey that examined the extent to which the practicing psychiatrists report that the information gained during the educational intervention actually resulted in sustained changes in their practice patterns would be useful in helping to define the enduring impact of such educational interventions on practice. Since a large body of CME research suggests that interventions using multiple strategies are more effective than those relying on only one type and that individualized practice-based interventions are more effective than traditional large-group didactic interventions (5), the long-term impact of CME programs such as the one described here would most likely be increased if they were supplemented with ongoing case-based study groups and/or other additional practice guideline-oriented interventions.
Finally, since 16% of the respondents were unaware even of the existence of the guidelines, and 44% were not aware that they were published in the American Journal of Psychiatry, a considerable challenge remains in disseminating information about practice guidelines. The APA's Steering Committee for Practice Guidelines has been experimenting with and considering the use of a number of additional methods to enhance both dissemination and the "user friendliness" of its guidelines. First, many of the newer guidelines are likely to be published with algorithms and "quick reference guides" to help practitioners rapidly focus on core recommendations. Newer guidelines have also been increasingly structured to address the practical problems and common complications associated with each major condition, not just to deal with the diagnostic entities per se. Second, some additional spin-offs, such as guidelines-based medical record prompts and checklists associated with various conditions, have been explored and may help. Third, the American Board of Psychiatry and Neurology recertification examinations are likely to rely heavily on APA practice guidelines as the basis for examination, and the ACP's Psychiatric Residents In-Training Examination will also increasingly use questions based on APA guidelines. Finally, the steering committee will also be able to consider the specific suggestions to increase dissemination offered by the survey respondents and further develop implementation strategies related to these ideas. As word of these developments reaches practitioners through Psychiatric News, local district-branch newsletters, and other dissemination venues, awareness about and salience of APA practice guidelines should increase. Since it is very likely that practice guidelines are here to stay and that they will increasingly influence medicine's practices, regulation, and reimbursement (6), dissemination strategies that improve practitioner's awareness and familiarity with these guidelines are highly desirable.
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ACKNOWLEDGMENTS
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The authors thank Rachel Spector, M.A., for her assistance in the statistical analysis of the data.
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REFERENCES
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Zarin D, Pincus HR, McIntyre JS: Practice guidelines. Am J Psychiatry 1993; 150:175–177[Free Full Text]
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Hirschfeld RMA, Clayton PJ, Cohen I, et al: Practice guideline for the treatment of patients with bipolar depression. Am J Psychiatry 1994; 15(suppl 12): 1–40
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Lomas J, Enkin M, Anderson GM, et al: Opinion leaders vs audit and feedback to implement practice guidelines: delivery after previous cesarean section. JAMA 1991; 265:2202–2207[Abstract/Free Full Text]
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Tunis SR. Hayward RS, Wilson MC, et al: Internists' attitudes about clinical practice guidelines. Ann Intern Med 1994; 120:956–963[Abstract/Free Full Text]
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Davis DA, Thomson MA, Oxman AD, et al: Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA 1995; 274:700–705[Abstract/Free Full Text]
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Greco PJ, Eisenberg JM: Changing physicians' practices. N Engl J Med 1993; 329:1271–1273[Free Full Text]
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ABSTRACT
INTRODUCTION
