title: Patient and physician related factors of adherence to evidence based guidelines in diabetes mellitus type 2, cardiovascular disease and prevention: a cross sectional study.
abstract: BACKGROUND
  Patients do not always receive guideline-adherent therapy, yet little is known about the underlying causes on the patients' side. We quantified non-guideline-adherent treatment of chronic diseases (diabetes mellitus, hypertension, cardiovascular disease, heart failure, atrial fibrillation) in primary care and analysed the causes from the physician's as well as the patient's view.
  
  
  METHODS
  With the intention to analyze the frequency and causes of non-guideline-adherent treatment of patients with chronic diseases, we drew a random sample of 124 general practitioners (GP) in Salzburg, Austria, of which 58 (46.8%) participated. In the participating GP surgeries, we consecutively recruited 501 patients with at least one of the target-diseases and checked the guideline conformity of treatment using 9 quality indicators. We then interviewed the patients as well as the general practitioners regarding factors affecting deviation from guideline recommendations.
  
  
  RESULTS
  Of the 501 patients, a total of 1224 quality indicators could be analysed. Non-adherence to guideline recommendations were present in 16.8% (n = 205, 95% CI 14.7 to 18.8%) of all quality indicators. In 61.5% of these cases (n = 126, 95% CI 53.0 to 70.0%) the treatment was wrongly judged as not recommended by the physicians. In 10.2% (n = 21, 95% CI 0 to 23.2%) physicians attributed non-adherence to patient's non-compliance, and in 10.7% (n = 22, 95% CI 0 to 23.7%) to an adverse drug event, whereas only 5.4% (n = 11, 95% CI 0 to 18.7%) of non-adherence was related to an adverse drug event reported by the patients. Patients were unaware regarding the reason for non-adherent therapy in 64.4% (n = 132, 95% CI 56.2 to 72.6%) of the quality indicators. In 20.0% (n = 41, 95% CI 7.8 to 32.2%) patients regarded a drug as not needed.
  
  
  CONCLUSIONS
  Guideline adherence in chronic care was relatively good in our study sample, but still leaving room for improvement. Physicians' lack of knowledge and patients' lack of awareness account for about 70% of non-adherence, indicating the necessity to improve physician education, and patient involvement. In about 30% of the quality indicators not fulfilled, non-adherence is due to other reasons like adverse drug events or patients not willing to take a recommended drug.
authors.affiliation: Institute of General Practice and Family Medicine, University of Witten/Herdecke, Witten, Germany. johanna.fuerthauer@pmu.ac.at
authors.forename: Johanna
authors.initials: J
authors.lastname: Fürthauer
authors.forename: Maria
authors.initials: M
authors.lastname: Flamm
authors.forename: Andreas
authors.initials: A
authors.lastname: Sönnichsen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001317:Austria / Q000453:epidemiology; D002318:Cardiovascular Diseases / Q000517:prevention & control*; D002908:Chronic Disease / Q000453:epidemiology; D002983:Clinical Competence / Q000592:standards; D015897:Comorbidity; D003430:Cross-Sectional Studies; D003924:Diabetes Mellitus, Type 2 / Q000517:prevention & control*; D019317:Evidence-Based Medicine; D005260:Female; D019983:Guideline Adherence / Q000592:standards*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008019:Life Style; D008297:Male; D010349:Patient Compliance / Q000523:psychology* / Q000706:statistics & numerical data; D010821:Physicians, Family / Q000523:psychology* / Q000706:statistics & numerical data; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data
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