Physicians' reasons for deviating from quality guidelines are usually justified

Research Activities, July 2010, No. 359

A variety of best practice guidelines contribute to improved quality of care. There are times, however, when physicians deviate from these guidelines in the care and treatment of a particular patient. Some electronic health record (EHR) systems notify physicians when this takes place and allow them to indicate their reasons for making an exception to recommended practices (quality measures). A new study finds that in the vast majority of cases, the exceptions made by physicians are considered appropriate.

Researchers studied data from an internal medicine practice located in a large city and affiliated with an academic medical center. All of the 39 physicians who worked at the practice used an EHR system. Whenever a quality measure was unaddressed in a patient, the EHR system alerted the physician to the discrepancy. At this time, explanations could be entered as to why the measure was not met. A panel of medical experts reviewed all cases where physicians made an exception to 1 or more of 16 chronic disease and prevention quality measures. Physicians were then provided feedback regarding their exception decision and allowed to change their management of the patient.

During the 7-month study, there were 650 medical exceptions. Medical reasons were not provided in 36 of these instances. The expert panel found that 93.6 percent of the remaining 614 exceptions were deemed medically appropriate. Only 3.1 percent were considered inappropriate. The panel was uncertain as to the appropriateness of the remaining exceptions. Inappropriate exceptions were most frequently reported for heart disease, diabetes, and prevention services. After receiving feedback on their exception decisions, physicians changed the way they managed the patient in 42 percent of these cases (8 out of 19). The study was supported in part by the Agency for Healthcare Research and Quality (HS17163 and HS15647).

See "Frequency of inappropriate medical exceptions to quality measures," by Stephen D. Persell, M.D., M.P.H., Nancy C. Dolan, M.D., Elisha M. Friesema, B.A., and others in the February 16, 2010, issue of Annals of Internal Medicine 152(4), pp. 225-231.

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