title: Response to the National Cancer Institute Alert. The effect of practice guidelines on two hospitals in the same medical community.
abstract: BACKGROUND
  Despite the recent increase in medical practice guideline development and dissemination, physician compliance with the guidelines has often been low. Previous research has suggested that physicians at hospitals with low volumes of cases and weakened financial status were more likely to omit indicated diagnostic testing or appropriate treatment. The authors sought to determine whether differences in compliance to a widely disseminated set of guidelines would exist even among the most dominant hospital providers within the same medical community.
  
  
  METHODS
  Two hospitals, together providing nearly half of the cancer surgery within a metropolitan area, were studied for their compliance to the May 1988 National Cancer Institute (NCI) Clinical Alert regarding 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 determined those patients who had received any form or combination of adjuvant therapy after primary surgical treatment (lumpectomy or modified radical mastectomy).
  
  
  RESULTS
  Following modified radical mastectomy, for women age 50 and older, the university hospital (U) provided adjuvant therapy to a higher percentage of patients than the community hospital (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 of age, the two hospitals were equally likely to provide adjuvant therapy both before and after the Alert. Following lumpectomy, hospital U increased 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 provided no adjuvant therapy before or after the Alert. Preferences for breast conserving surgical treatment were significantly (P < 0.001) different with hospital U performing a higher percentage of lumpectomies than hospital C both before (50.9% versus 14.9%) and after (57.6% versus 16.8%) the Alert.
  
  
  CONCLUSIONS
  Significant differences in compliance with practice guidelines may be found even among the most dominant hospital providers of cancer services within the same medical community. The role of the surgeon in referring patients to the oncologist greatly influences the ultimate provision of adjuvant therapy. Strategies for enhancing compliance should be considered integral to the process of guideline development.
authors.affiliation: Department of Health Policy and Management, College of Public Health, University of South Florida, Tampa 33612.
authors.forename: J
authors.initials: J
authors.lastname: Studnicki
authors.forename: D V
authors.initials: DV
authors.lastname: Schapira
authors.forename: D D
authors.initials: DD
authors.lastname: Bradham
authors.forename: R A
authors.initials: RA
authors.lastname: Clark
authors.forename: A
authors.initials: A
authors.lastname: Jarrett
mesh_terms: D000367:Age Factors; D001943:Breast Neoplasms / Q000628:therapy*; D017024:Chemotherapy, Adjuvant; D016009:Chi-Square Distribution; D003131:Combined Modality Therapy; D003153:Community Health Services; D005260:Female; D006764:Hospitals, Community; D006785:Hospitals, University; D006801:Humans; D007255:Information Services; D015411:Mastectomy, Modified Radical; D015412:Mastectomy, Segmental; D008875:Middle Aged; D009316:National Institutes of Health (U.S.); D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D014481:United States