The awareness-to-adherence model of the steps to clinical guideline compliance - The case of pediatric vaccine recommendations
The awareness-to-adherence model of the steps to clinical guideline compliance - The case of pediatric vaccine recommendations
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DOI：
10.1097/00005650-199609000-00002
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发表时间：
1996-09-01
期刊：
影响因子：
3
通讯作者：
Koch, GG
中科院分区：
文献类型：
--
作者：
Pathman, DE;Konrad, TR;Koch, GG
目标。本文提出、测试并探讨了医生在遵守国家临床实践指南时所采取的认知和行为步骤模型的潜在应用。作者建议，当医生遵守实践指南时，他们必须首先意识到这些指南，然后理智地同意这些指南，然后决定在他们提供的护理中采用这些指南，然后在适当的时候定期遵守这些指南。用于测试该模型的数据涉及医生对国家儿科疫苗建议的反应。问卷邮寄给在九个州不同规模的社区工作的3014名家庭医生和儿科医生。调查回复率为66.2%。在建议向所有婴儿提供乙肝疫苗的案例中，应答者对指南的知晓率为98.4%，同意率为70.4%，采纳率为77.7%，遵守率为30.1%。87.9%的医生的数据在每一步都符合模型。只有11%的采纳了乙肝建议但不同意的医生与模型存在显著偏差。在建议为儿童第四剂和第五剂百日咳提供无细胞品种百日咳疫苗的情况下，受访者中对指南的认知度为89.8%，同意率为66.5%，采纳率为46.3%，遵守率为35.2%。90.6%的医生每一步的数据都符合模型。对于具有特定特征、信息来源和对疫苗的信念的医生，以及在特定类型的实践环境中，从每一步到下一步的可能性更大。特定的医生和实践特征通常预测仅沿着一个或两个步骤的运动，以坚持乙型肝炎或非细胞性百日咳的建议。这些关于医生使用儿科疫苗建议的数据通常支持“意识到坚持”模型。该模型可以通过展示医生在哪些地方偏离了遵循指南的路径，哪些医生没有达到每一步的风险最大，以及与更有可能达到遵循指南的每一步相关的因素，来确定提高医生对各种指南的依从性的方法。
OBJECTIVES. This article proposes, tests, and explores the potential applications of a model of the cognitive and behavioral steps physicians take when they comply with national clinical practice guidelines. The authors propose that when physicians comply with practice guidelines, they must first become aware of the guidelines, then intellectually agree with them, then decide to adopt them in the care they provide, then regularly adhere to them at appropriate times.METHODS. Data used to test this model address physicians' responses to national pediatric vaccine recommendations. Questionnaires were mailed to 3,014 family physicians and pediatricians who were working in communities of various sizes in nine states.RESULTS. The survey response rate was 66.2%. In the case of the recommendation to provide hepatitis B vaccine to all infants, guideline awareness among respondents was 98.4%, agreement 70.4%, adoption 77.7%, and adherence 30.1%. The data for 87.9% of physicians fit the model at every step. Significant deviation from the model occurred only for the 11% of all physicians who adopted the hepatitis B recommendation without agreeing with it. In the case of the recommendation to provide the acellular variety of the pertussis vaccine for children's fourth and fifth pertussis doses, guideline awareness among respondents was 89.8%, agreement 66.5%, adoption 46.3%, and adherence 35.2%. Data fit the model at every step for 90.6% of physicians. Greater likelihood of movement from each step to the next in the path to adherence was found for physicians with certain characteristics, information sources, and beliefs about the vaccines, and those in certain types of practice settings. Specific physician and practice characteristics typically predicted movement along only one or two of the steps to adherence to either the hepatitis B or acellular pertussis recommendations.CONCLUSIONS. These data on physicians' use of pediatric vaccine recommendations generally support the awareness-to-adherence model. This model may prove useful in identifying ways to improve physicians' adherence to a variety of guidelines by demonstrating where physicians fall off the path to adherence, which physicians are at greatest risk for not attaining each step in the path, and factors associated with a greater likelihood of attaining each step toward guideline adherence.