Sources of variation in physician adherence with clinical guidelines: results from a factorial experiment.

BACKGROUND: Health services research has documented the magnitude of health care variations. Few studies focus on provider level sources of variation in clinical decision making-for example, which primary care providers are likely to follow clinical guidelines, with which types of patient. OBJECTIVES: To estimate: (1) the extent of primary care provider adherence to practice guidelines and the unconfounded influence of (2) patient attributes and (3) physician characteristics on adherence with clinical practice guidelines. DESIGN: In a factorial experiment, primary care providers were shown clinically authentic video vignettes with actors portrayed different "patients" with identical signs of coronary heart disease (CHD). Different types of providers were asked how they would manage the different "patients" with identical CHD symptoms. Measures were taken to protect external validity. RESULTS: Adherence to some guidelines is high (over 50% of physicians would follow a third of the recommended actions), yet there is low adherence to many of them (less than 20% would follow another third). Female patients are less likely than males to receive 4 of 5 types of physical examination (p < .03); older patients are less likely to be advised to stop smoking (p < .03). Race and SES of patients had no effect on provider adherence to guidelines. A physicians' level of experience (age) appears to be important with certain patients. CONCLUSIONS: Physician adherence with guidelines varies with different types of "patient" and with the length of clinical experience. With this evidence it is possible to appropriately target interventions to reduce health care variations by improving physician adherence with clinical guidelines.

Upstream healthy public policy: lessons from the battle of tobacco.

Many consider public health and politics to be entirely separate worlds. Public health activities are generally well-motivated by public interest, perceived as value-free, scientific, and devoid of partisan preference. Politics, in contrast, can be viewed as a distasteful activity involving self-interested pressure groups, misuse of state power, and influence of money on national decisions. Public health and politics are inappropriate bedfellows if politics is reduced to party politics. Politics, of course, involves more than just party activities; it concerns the structure, distribution, and effects of power in society. Which groups pattern the social order? What are their sources of influence? How do they retain privileged status? What social effects result from the policies these groups shape? Viewed in this broader sense, politics is essential for effective public health and thus is the inescapable context of public health interventions. To disregard sociopolitical determinants of health is to relegate public health to prevention and promotion of individual risk behaviors. If public health is to be more successful in the 21st century, it must comprehend the magnitude of the forces against it and the strategies used to engineer its defeat. Public health interventions in the new millennium must be appropriate to their sociocultural context.

To boldly go....

The threshold of the new millennium offers an opportunity to celebrate remarkable past achievements and to reflect on promising new directions for the field of public health. Despite historic achievements, much will always remain to be done (this is the intrinsic nature of public health). While every epoch has its own distinct health challenges, those confronting us today are unlike those plaguing public health a century ago. The perspectives and methods developed during the infectious and chronic disease eras have limited utility in the face of newly emerging challenges to public health. In this paper, we take stock of the state of public health in the United States by (1) describing limitations of conventional US public health, (2) identifying different social philosophies and conceptions of health that produce divergent approaches to public health, (3) discussing institutional resistance to change and the subordination of public health to the authority of medicine, (4) urging a move from risk factorology to multilevel explanations that offer different types of intervention, (5) noting the rise of the new "right state" with its laissez-faire attitude and antipathy toward public interventions, (6) arguing for a more ecumenical approach to research methods, and (7) challenging the myth of a value-free public health.