Why do doctors ignore guidelines

A study presented at the Society of Gynecologic Oncology found that only 37%  of patients with ovarian cancer treated in California from 1999 to 2006 were treated according to guidelines promulgated by the National Comprehensive Cancer Network, a group of 21 academic cancer treatment centers. Showing that the guidelines reflect optimal care, in this study 35% of those who were treated according to the guidelines survived at least 5 years compared to 25% who were not so treated.

There have been other studies showing that doctors do not always follow expert guidelines. In one, a RAND Corporation study found that for a wide variety of medical conditions, only 45% received care consistent with guidelines.

Why do doctors fail to follow guidelines?  As a former practicing pediatrician I believe I can speak to this issue.  Doctors can be stuck in a rut, doing what they always do.  They may not be reading or going to professional meetings to keep up with the latest studies and guidelines. 

The academically based doctors that are real experts in their field may not agree with all the approaches for all of their patients. Since not all guideline recommendations are based on clinical trials but on expert opinion, this is bound to happen .Unfortunately many doctors consider their own experience expertise enough to challenge the guidelines and continue their management the way they have always done it, even if there is good evidence that there are better approaches.

Guidelines regarding management of ear infections in children were promoted in 2004 by the American Academy of Pediatrics that included an option of watchful waiting over immediate antibiotics, a new approach that had I been still in pediatric practice would have been interesting to see how well I myself would have complied to the new recommendations. With parents used to getting antibiotics for their kids' ear infections the observation option with pain control only would be sure to be a hard sell. The guidelines also recommended which antibiotics should be used. A survey of pediatricians in 2006 found that for four common clinical scenarios, based on severity of symptoms and prior antibiotic choice, from 13% to 57% of the respondents agreed with the guidelines.Why such a difference? All these "experts" rejecting the recommendations of the real experts!  One of the treatments was 3 days of an expensive antibiotic shot, sure to be a problem for parents and doctors both. There also was a possibility that the bacteria  that cause ear infections were changing and based on that the antibiotic choices would change.  The authors of the survey also speculate that parental preferences and pharmaceutical company advertising and provision of free antibiotic samples may influence antibiotic choice. 

In a news story on this ovarian cancer study on Boston.com it was noted that another reason patients do not get optimal care is that it only can be given at academic medical centers. Not all patients can afford to travel those distances or have health insurance to cover out of area or network care.  

It is particularly ironic that the news about this ovarian cancer study came out this week as I developed fever and neutropenia due to  CHOP-R and had to be admitted to hospital for IV antibiotics after multiple cultures.  Since I have had febrile neutropenia at least 3 times in the past, after fludarabine, I was not surprised.  Perhaps I should have been surprised that I was not given a granulocyte-colony stimulating factor (G-CSF) like Neulasta or Neupogen after that first day of  chemo. I did get Neulasta after bendamustine treatments in the past.  Having my laptop with me in hospital I looked up the American Society of Clinical Oncology guidelines for using G-CSFs.  This document, published in 2006, recommends using a G-CSF when the risk for febrile neutropenia is over 20%.  The study of  CHOP-R in lymphoma patients found a febrile neutropenia rate of only 18% so my oncology team was not amiss in forgoing using Neulasta on the first cycle. But wait the guidelines also say this:

Certain clinical factors predispose to increased complications from prolonged neutropenia, including: patient age greater than 65 years; poor performance status; previous episodes of FN; extensive prior treatment including large radiation ports; administration of combined chemoradiotherapy; cytopenias due to bone marrow involvement by tumor; poor nutritional status; the presence of open wounds or active infections; more advanced cancer, as well as other serious comorbidities. In such situations, primary prophylaxis with CSF is often appropriate even with regimens with FN rates less than 20%. This was the consensus opinion of the expert committee. Such high-risk patients are most often excluded from clinical trials, and this is not a situation likely to have additional clinical data.

So maybe my past history should have led the team to use Neulasta as I have had febrile neutropenia before but maybe that was not in my record at Penn.Maybe the poor status of my marrow with the prolonged anemia and low platelets, but that was actually improving at the time. So  I am confident my oncology team had the right judgement, but ask myself whether I should have reminded them of my history. If I had received the very expensive Neulasta - $2000-6000 for a single dose(depending on what your oncologist can charge your insurance)  - it would have prevented a much more expensive hospitalization. Oh well, water under the bridge.