RESPONSE TO THE NATIONAL-CANCER-INSTITUTE ALERT - THE EFFECT OF PRACTICE GUIDELINES ON 2 HOSPITALS IN THE SAME MEDICAL COMMUNITY

Background. Despite the recent increase in medical practice guideline development and dissemination, physician compliance with the guideline s has often been low. Previous research has suggested that physicians at hospitals with low volumes of cases and weakened financial status w ere more likely to omit indicated diagnostic testing or appropriate tr eatment. The authors sought to determine whether differences in compli ance to a widely disseminated set of guidelines would exist even among the most dominant hospital providers within the same medical communit y. Methods. Two hospitals, together providing nearly half of the cance r surgery within a metropolitan area, were studied for their complianc e to the May 1988 National Cancer Institute (NCI) Clinical Alert regar ding adjuvant therapy after primary treatment for node negative breast cancer. A case series consecutive collection of 549 women treated at the study hospitals for 2 years before and two years after the Alert d etermined those patients who had received any form or combination of a djuvant therapy after primary surgical treatment (lumpectomy or modifi ed radical mastectomy). Results. Following modified radical mastectomy , for women age 50 and older, the university hospital (U) provided adj uvant therapy to a higher percentage of patients than the community ho spital (C) both before (25.6% versus 4.7%, P < 0.005) and after (58.9% versus 23.2%, P < 0.001) the Alert. For women younger than 50 years o f age, the two hospitals were equally likely to provide adjuvant thera py both before and after the Alert. Following lumpectomy, hospital U i ncreased the percentage of women receiving adjuvant therapy following the Alert in women younger than 50 years of age (25-75.8%, P < 0.001) and in women age 50 and older (33.3-56.5%, P < 0.025). Hospital C prov ided no adjuvant therapy before or after the Alert. Preferences for br east conserving surgical treatment were significantly (P < 0.001) diff erent with hospital U performing a higher percentage of lumpectomies t han hospital C both before (50.9% versus 14.9%) and after (57.6% versu s 16.8%) the Alert. Conclusions. Significant differences in compliance with practice guidelines may be found even among the most dominant ho spital providers of cancer services within the same medical community. The role of the surgeon in referring patients to the oncologist great ly influences the ultimate provision of adjuvant therapy. Strategies f or enhancing compliance should be considered integral to the process o f guideline development.