In-depth assessment of Iraqi physicians' adherence to treatment guidelines for different diseases: a qualitative study

Study design

This qualitative study consisted of individual interviews with physicians from various specialties (cardiology, rheumatology, gynecology, pediatrics, neurology, and nephrology) who have worked with the treatment guidelines. Nevertheless, the sample size was chosen by the data saturation threshold, a crucial feature of these types of investigations. In other words, data collection ceased when a saturation level was reached and no additional data could be gathered (i.e., new participants were repeating the same previous answers). Specialists completed semi-structured interviews. The study’s stated methodological orientation was thematic analysis. To approach participants, face-to-face interviews were used. This study includes both male and female specialists, who were selected using a purposive sampling method.⁹ Two physicians refused to participate because they were not interested.

Settings

Almost all interviews were performed face-to-face at Kirkuk province’s public hospitals. The study’s time frame was from December 2021 to May 2022. Each interview lasted 10–15 minutes. Demographic data were used for the sample description.

Eligibility criteria

Participating in the research were physicians who worked in public hospitals, had experience with guidelines, and one of the following specialties: internal medicine, nephrology, gynecology, neurology, cardiology, rheumatology and pediatrician.

Exclusion criteria

The exclusion criteria for the study were physicians with specialties not covered in our study specialty and other health workers who did not deal with guidelines.

In order to remove prejudice, participants with hearing, speech, or cognitive impairments that hinder topic understanding were eliminated from the sample.

Study Sampling

A purposive sampling method was used to select physicians who work in public hospitals in the province of Kirkuk was taken between December 2021 and May 2022. The physicians were invited in-person to participate in the study. The purposive sampling method was done to identify “individuals who have extensive knowledge of or experience with an interesting phenomenon”.^10,11 The researchers also employed a snowball method. The term “snowballing” refers to the practice of asking participants to recommend specialists who might be willing to take part in the research and who fit the inclusion criteria. Hence, the study employed two sampling techniques: purposive and snowball. One researcher conducted in-person interviews during face-to-face hospital meetings. Some participants asked for the interview guide ahead of time so they could Prepare themselves for answers and to save time. The interviews continued until the point of data saturation was achieved. Optional audio recording was available because it could deter potential interviewers from participating. The physicians who rejected the recording given handwritten responses in addition to notes taking by the interviewer during the interview.

The author was a male pharmacist with five years of experience and a Bachelor of Science in pharmacy. Before the study began, a good rapport was established with the participants, and they were informed that the author is a master’s student. Each interview lasted 10–15 minutes and was conducted in hospitals. Two bilingual authors translated the Arabic sentences (transcripts) into English. Interviews were performed in English, Arabic, Kurdish, and Turkish languages (mixed languages based on the participant’s English proficiency). Participants were given interview instructions (questions) by the author. No repeated interviews were conducted. Several individuals were interviewed using an audio recorder. Notes taken during and following interviews. The audio data were written words by words (transcribed verbatim) by the researchers. Data saturation is typically defined by researchers as “the point when “no new information or themes are observed in the data.

Interview guide

This study was conducted to evaluate the adherence of Iraqi physicians to medical guidelines for the treatment of various diseases. The interview guide was broken up into two parts. Part-1 included full participant characteristics were gender, occupation, level of education, professional title, area of expertise, years of practice, and workplace. Part-2 consisted of eleven questions posed to specialists in various fields (Table 1). The interview guide was not piloted. The interview began by introducing the researcher and the purpose of the study. The names of participants were not reported.

Ethical approval

The Scientific Committee at the Department of Clinical Pharmacy and the Central Ethical Committee of the College of Pharmacy at Baghdad University reviewed and approved the research proposal including objectives and methodologies (ethics board approval number:2206). Before administering the interview questions, the researcher described the goal of the study and got each participant's verbal consent. Participants were not provided with any incentives. The interviewees’ information was maintained confidential.

Thematic analysis

The qualitative data obtained from the interviews was analyzed using thematic analysis. During the data’s thematic analysis, Based on participant comments, two authors (AA and IY) reviewed the text and constructed themes. We followed Braun and Clarke’s six phases of thematic analysis, which included acquainting ourselves with the data (comments), generating initial codes, searching for themes, evaluating themes, defining and naming themes, and writing the report.¹² As quotations, the completed statements (ideally with examples) were selected. The study team double-checked the transcription. The qualitative analysis was reviewed by peers and debriefed to make sure that the results were accurate and trustworthy. A data-driven inductive analytic technique and a constructivist worldview were employed.¹⁰ This means that, rather than relying on a pre-existing framework, we derived the themes from prevalent patterns that emerged from the participant responses. The data was coded with two data codes. The author failed to provide a description of coding trees. No software was utilized in this study. There was consistency between the presented data and the findings. The findings clearly present major and minor themes. Finally, peer verification and debriefing were conducted twice to confirm the findings.

Demographics

Using medical guidelines to cover nearly all specialties was one of the study’s strengths, and the majority of participants were well-regarded professionals having considerable experience. The study’s participants were physicians with knowledge or expertise of medical guidelines; thus, the findings may not be representative of all physicians.¹⁴

The adherence of physicians to medical guidelines in their treatment approaches

In fact, the majority of specialists had good expertise with guidelines in their respective branches, and they stated as much (they follow new updates in the guidelines to apply new recommendations to patients in order to get the best results in their treatment approach). In this study, the author observed that specialists almost always adhere to the most well-known and globally dependable guidelines due to their postgraduate studies based on these guidelines, as well as because these guidelines are simple and applicable to our society and provide the greatest benefits. Unfortunately, senior physicians (specialists) did not follow all of the guidelines’ recommendations due to the barriers and other reasons that have already been mentioned. Specialists’ approaches to treatment were unaffected by gender since they adhered to the same guidelines.⁹ Several studies analyzed the primary information sources on antibiotics utilized by physicians. The majority of physicians in the studies were familiar with antibiotic prescribing recommendations, although some did not follow them. In Sudan, for instance, only 32.6% of physicians resorted to the Sudan National Formulary or the British National Formulary while making decisions, while the remainder did not consult any reference source.¹⁵

Unavailability of Iraqi treatment guidelines for various diseases

According to the majority of specialists, there are no Iraqi guidelines that cover the majority of diseases in their respective branches, which were covered in this study. There is no established central organization in Iraq that develops guidelines for the majority of diseases treated in public health care settings. Additionally they inform the Ministry of Health and the medical associations to make Iraqi guidelines that are more useful, adaptable to our community, and in line with the facilities in our country.

Specialists’ connections to physicians and clinical pharmacists

There were good connections and discussions between specialist physicians and permanents and rotators regarding diseases and guidelines, whereas there were few discussions with pharmacists regarding guidelines. A previous Iraqi study found low physician acceptance of pharmacist recommendations suggests that physicians may underestimate the risk of drug-drug interactions. In fact, some of these contacts were classified as grave mistakes.¹⁶

Adherence of specialists to guidelines within a specific specialty

According to their experience with patients and diseases, the majority of senior physicians in one specialty followed the same guidelines with minor variations in details. For example, some specialists chose valsartan while others chose candesartan from the same ARBs group. This could be due to their board/post-residency training program, their experiences with patients, and the results they obtained from implementing these guidelines. It was worth mentioning Iraqi physicians rely on the most well-known and reliable guidelines in the world, such as the American guidelines, which were utilized most frequently by the participating physicians and hospitals. Some specialties also follow European and British recommendations.

Access to approved medications and diagnostic tools in public health settings

The majority of medications and investigational tools that aid physicians in disease diagnosis were scarce or unavailable in Iraqi public health care settings. The shortage of life-saving treatments and the absence of important centers such as the stroke unit in all hospitals in the province make it difficult for specialists to diagnose and treat such cases, forcing them to refer patients to the private sector or recommend medication and lab tests from outside (private settings).

Numerous barriers impeded the implementation of the guidelines by physicians in public hospitals

Regarding the implementation of guidelines for the treatment of various diseases, physicians faced significant barriers. Major barriers were the unavailability or shortage of medications; investigational tools (laboratory tests, x-rays, MRIs, CT scans, etc.); patients’ education; adherence; and physician follow-up. Incapability to properly answer questions on the content of the guidelines, as well as self-reported unfamiliarity with the material, constituted a lack of familiarity. About two-thirds of the physicians were willing to prescribe low-cost medications, but only about half of them reported prescribing generic medications to their patients. This indicates a discrepancy between physician intent and prescribing behavior. Again, the risk of therapeutic failure is a key concern for physicians when they prescribe generic medications, especially in the private sector.¹⁷ Lack of cognition Due to the ever-increasing volume of research, it is challenging for a physician to be aware of and properly implement all applicable guidelines. Lack of acquaintance Awareness does not necessarily imply familiarity with and the ability to successfully apply guidelines.¹⁸ Iraqi physicians favored biosimilar medications licensed by the U.S. FDA and the European Medicines Agency (EMA). This is likely due to their increased confidence in the stringent restrictions of the U.S. FDA and the EMA about the approval of safe and effective biosimilars. On the other hand, the fact that biosimilar medicines made in neighboring countries and brought into Iraq may not have these international approval certifications makes it much harder for physicians to accept them.¹⁹

Absence of Agreement Doctors may disagree with a particular guideline or the notion of recommendations. In general, although physicians frequently indicate disagreement when questioned about guidelines theory, this and previous analyses indicate that disagreement is less prevalent when physicians are asked about specific guidelines.²⁰

Lack of outcome expectations the expectation that a specific consequence will result from a particular behavior. If physicians perceive that a recommendation would not improve patient outcomes, they will be less inclined to follow it.²¹

A previous study indicated individual obstacles, including EBM skills (79.0%) and time (61.9%), were identified the most frequently. The fact that societal circumstances and legislation restrict the usefulness of evidence (55.2%), that there is no control over the practice of evidence (45.7%), and that the evidence is too difficult or theoretical to apply to practice (47.6%) were also frequently cited as impediments.²² Patients may be resistant to or think guideline recommendations are unnecessary. Additionally, a patient may find the recommendation disrespectful or embarrassing. Conformity to practice guidelines “may necessitate non-physician-controlled adjustments, such as the procurement of new resources or facilities”.^23,24 The respondents listed several barriers, like not having a reminder system, not having enough counseling materials, not having enough staff or consultant support, getting paid too little, having to pay more for practice costs, and having more liability, may be out of the doctors’ hands.²³ In advance, the barriers to guideline implementation and adherence in any given instance must be analyzed so that methods that are suited to the unique situation and target groups can be established. To be effective in influencing physicians’ behavior, the plan must involve a variety of intervention types and target physicians’ knowledge and attitudes.²⁴

Reasons for physicians to adhere to treatment guidelines in their treatment approach

The majority of participating physicians rely on and adhere to guidelines for a variety of reasons, including that they are simple to use, based on real-world studies, more applicable in our society, updated, provide good results/benefits, are used globally, and have been taught in our post-graduate/specialty program.

Implementation rate of the guidelines by physicians in their daily work

The type of guideline used varied a lot from branch to branch and from ward to ward, depending on the hospital. Due to the many barriers that were pointed out in this study, most specialists said that less than 70% of guideline were followed. However, some specialists said that more than 70% of recommendations were followed in some cases and diseases.

Follow the recommendations of the guidelines in both public and private settings

The majority of specialists followed the same guidelines Across both the private and public sectors. In the private sector, some physicians use their experience or a mix of guidelines. However, the large number of facilities available in the private sector gives physicians a lot of options and flexibility in how they treat their patients.

Limitations

As a qualitative study, the findings may not necessarily be generalized to the whole specialists. However, by using a maximum variation sampling approach, whereby we collected data from various types of specialists, the researcher been able to capture a wide spectrum of attitudes and practice which is likely to reflect practice in the broader profession. In addition, the study didn’t cover all diseases and all medical branches. The vast majority of physicians refused to record interviews and crowded consultant clinics, which were interrupted interviews.