title: Adherence by primary care physicians to guidelines for the clinical management of dyslipidemia.
abstract: BACKGROUND
  There is a wide treatment gap between evidence-based guidelines and their implementation in primary care.
  
  
  OBJECTIVE
  To evaluate the extent to which physicians "literally" follow guidelines for secondary prevention of dyslipidemia and the extent to which they practice "substitute" therapeutic measures.
  
  
  METHODS
  We performed a post hoc analysis of data collected in a prospective cluster randomized trial. The participants were 130 primary care physicians treating 7745 patients requiring secondary prevention of dyslipidemia. The outcome measure was physician literal adherence or substitute adherence. We used logistic regressions to evaluate the effect of various clinical situations on literal and substitute adherence.
  
  
  RESULTS
  Literal adherence was modest for ordering a lipoprotein profile (35.1%) and for pharmacotherapy initiations (26.0%), but rather poor for drug up-titrations (16.1%) and for referrals for specialist consultation (3.8%). In contrast, many physicians opted for substitute adherence for up-titrations (75.9%) and referrals for consultation (78.7%). Physicians tended to follow the guidelines literally in simple clinical situations (such as the need for lipid screening) but to use substitute measures in more complex cases (when dose up-titration or metabolic consultation was required). Most substitute actions were less intense than the actions recommended by the guidelines.
  
  
  CONCLUSIONS
  Physicians often do not blindly follow guidelines, but rather evaluate their adequacy for a particular patient and adjust the treatment according to their assessment. We suggest that clinical management be evaluated in a broader sense than strict guideline adherence, which may underestimate physicians' efforts.
authors.affiliation: Department of Industrial Engineering and Management, Ben-Gurion University of the Negev, Beer Sheva, Israel.
authors.forename: Geva
authors.initials: G
authors.lastname: Vashitz
authors.forename: Joachim
authors.initials: J
authors.lastname: Meyer
authors.forename: Yisrael
authors.initials: Y
authors.lastname: Parmet
authors.forename: Yaakov
authors.initials: Y
authors.lastname: Henkin
authors.forename: Roni
authors.initials: R
authors.lastname: Peleg
authors.forename: Nicky
authors.initials: N
authors.lastname: Liebermann
authors.forename: Harel
authors.initials: H
authors.lastname: Gilutz
mesh_terms: D050171:Dyslipidemias / Q000175:diagnosis / Q000188:drug therapy*; D005194:Family Practice / Q000706:statistics & numerical data*; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010821:Physicians, Family; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012017:Referral and Consultation