Clinical guidelines and clinical autonomy: exploring the missing link

PurposeThis paper aims at understanding how clinical guidelines' use in the labour process relates to clinical autonomy, that is, the self-control medical professionals exercise over medical practice.Design/methodology/approachDrawing on a qualitative case study research strategy, this paper explores how medical professionals use clinical guidelines in the labour process in one public general hospital of the Greek National Health System. Supplemented by an extensive study of documents, semi-structured interviews were conducted with 33 doctors of several specialties.FindingsThe analysis shows (1) how clinical autonomy, as a self-control structure, mediates the use of clinical guidelines as a knowledge tool in the labour process, and (2) how employing clinical guidelines as a means towards coordinating medical work, but also towards regulating and standardising medical practice, is exercising pressure on the individualistic character of clinical autonomy.Originality/valueAdvancing the analytic value of workplace control structures, this paper contributes novel theoretical understanding of emerging tendencies characterising medical work organisation and clinical autonomy, and explains how medical professionals' non-adherence to clinical practice guidelines (CPGs) relates to CPGs' role as a resource to medical practice. Finally, this research proposes a more critical approach to health policy towards addressing the challenges associated with centrally introducing clinical guidelines in healthcare organisations.

Nurse Practitioner Autonomy and Complexity of Care in Rural Primary Care

The growing ranks of nurse practitioners (NPs) in rural areas of the United States have the potential to help alleviate existing primary care shortages. This study uses a nationwide source of claims- and EHR-data from 2017 to construct measures of NP clinical autonomy and complexity of care. Comparisons between rural and urban primary care practices reveal greater clinical autonomy for rural NPs, who were more likely to have an independent patient panel, to practice with less physician supervision, and to prescribe Schedule II controlled substances. In contrast, rural and urban NPs provided care of similar complexity. These findings provide the first claims- and EHR-based evidence for the commonly held perception that NPs practice more autonomously in rural areas than in urban areas.

Factors that influence rheumatologists’ anti-tumor necrosis factor alpha prescribing decisions: a qualitative study

Background Treatment decisions for any disease are usually informed by reference to published clinical guidelines or recommendations. These recommendations can be developed to improve the relative cost-effectiveness of health care and to reduce regional variation in clinical practice. Anti-tumor necrosis factor alpha (anti-TNF) treatments are prescribed for people with rheumatoid arthritis according to specific recommendations by the National Institute for Health and Care Excellence in England. Evidence of regional variation in clinical practice for rheumatoid arthritis may indicate that different factors have an influence on routine prescribing decisions. The aim of this study was to understand the factors that influence rheumatologists’ decisions when prescribing anti-TNF treatments for people with rheumatoid arthritis in England. Methods Semi-structured one-to-one telephone interviews were performed with senior rheumatologists in different regions across England. The interview schedule addressed recommendations by the National Institute for Health and Care Excellence, prescribing behavior, and perceptions of anti-TNF treatments. Interviews were recorded digitally, transcribed verbatim, and anonymized. Data were analyzed by thematic framework analysis that comprised six stages (familiarization; coding; developing the framework; applying the framework; generating the matrix; interpretation). Results Eleven rheumatologists (regional distribution - north 36%; midlands: 36%; south: 27%) participated (response rate: 24% of the sampling frame). The mean duration of the interviews was thirty minutes (range: 16 to 56 min). Thirteen factors that influenced anti-TNF prescribing decisions were categorized by three nested primary themes; specific influences were defined as subthemes: (i) External Environment Influences (National Institute for Health and Care Excellence Recommendations; Clinical Commissioning Groups; Cost Pressures; Published Clinical Evidence; Colleagues in Different Hospitals; Pharmaceutical Industry); (ii) Internal Hospital Influences (Systems to Promote Compliance with Clinical Recommendations; Internal Treatment Pathways; Hospital Culture); (iii) Individual-level Influences (Patient Influence; Clinical Autonomy; Consultant Experience; Perception of Disease Activity Score-28 (DAS28) Outcome). Conclusions Factors that influenced anti-TNF prescribing decisions were multifaceted, seemed to vary by region, and may facilitate divergence from published clinical recommendations. Strategic behavior appeared to illustrate a conflict between uniform treatment recommendations and clinical autonomy. These influences may contribute to understanding sources of regional variation in clinical practice for rheumatoid arthritis.

Challenges in regulating priority setting in healthcare: A Finnish perspective on the lawmaker’s dilemma

Healthcare rationing presents multiple problems for the lawmaker. This article examines them through two legislative projects concerning Finnish healthcare and the scope of professional discretion awarded to physicians in priority setting. In attempting to enact norms to steer decision-making in priority setting, the lawmaker has to balance tensions between individual and community rights; for example, relating to legal safeguards, equal access, clinical autonomy, individual need, and transparency. Physicians exercise significant discretion over rationing in a context of rising pressure to contain costs, without support from precise decision-making criteria set in legislation. This raises concerns over the long-term legitimacy of priority setting in Finland. The article argues that legal research should provide analyses of legislative measures and the wider regulatory mix to ensure that priority setting frameworks are compatible with the right to health, and that best practices presented in international priority setting research are operationalized in legislative reforms.

State control and doctors’ abuse of clinical autonomy: An empirical analysis of doctors’ clinical practice in Chinese public hospitals

Medical doctors enjoy a high degree of professional autonomy because they own and apply professional knowledge in helping patients. Therefore, laymen are unable to evaluate doctors’ clinical practices. For this reason, how to exert effective social control over doctors’ work has been a significant question in the sociology of professions. Based on fieldwork in Beijing, government statistics, and others’ research findings, this paper analyzes the working conditions and clinical practices of Chinese urban doctors. I find that medical professionals are still dependent upon public hospitals that continue dominating the healthcare delivery system, and thus they lack corporate autonomy and are incapable of negotiating working arrangements, payment for their services and their incomes with the state. This condition generates a distortion in doctors’ labor value. However, also because of the domination of the healthcare delivery system, public hospitals and their doctors have gained ‘dual dominance’ over both patients and pharmaceutical enterprises, by which doctors transform their rights of prescription into economic benefits. This informal income, including hongbao (red envelopes containing money) and kickbacks, compensates for doctors’ relatively low formal incomes resulting from the state’s control. However, doctors abuse clinical autonomy constantly and pervasively, by which they transform their monopolies of medical expertise into economic benefits. This also means that the regulation and supervision of health administration is unsuccessful, as is the profession’s self-regulation. Hence, this paper suggests that if the medical profession can effectively participate in health policy-making, medical professionals be given the right of free practice, and non-public medical institutions given the same status and policy treatments as public hospitals, these problems in the current healthcare system will be relieved or solved.

Selective Consent and Dissent: Professional Response to Reform in the Post-Crisis Greek NHS

Utilising the sociology of the professions as an analytical framework, the article explores the response of the Greek medical profession to state-imposed managerialism during times of economic recession and socio-political turbulence. It is argued that the case of southern welfare states, permeated by clientelism and corruption, underpins a distinct form of professional–state relations, currently missing from relevant theoretical discussions. Rich qualitative data collected from practising hospital doctors in Greece reveal a willingness to concede elements of clinical autonomy in exchange for the minimisation of the role of a corrupt state in the organisation of the Greek National Health Service.