Pressure ulcers in adults: family physicians' knowledge, attitudes, practice preferences, and awareness of AHCPR guidelines - Agency for Health Care Policy and Research

Journal of Family Practice, April, 1997 by Shinji Kimura, James T. Pacala

Pressure ulcers are a commonly encountered condition in primary care. There is an ever increasing body of knowledge about pressure ulcers; a MEDLINE search revealed publication of at least seven comprehensive review articles in the past 5 years alone. (1-7) Despite this attention in the literature, little is known about physicians' knowledge, attitudes, and practice preferences with regard to pressure ulcers. A single survey, performed in the Netherlands, documented providers' opinions on pressure ulcer treatments, (8) but to date there have been no systematic surveys of primary care physicians' knowledge and management of this important clinical problem.

Recently, efforts have been made to heighten physicians' knowledge about pressure ulcers. In particular, two clinical practice guidelines on pressure ulcers have been developed by multidisciplinary expert panels for the Agency for Health Care Policy and Research (AHCPR) to help physicians make decisions about pressure ulcer prevention and treatment. (9-12) The first guideline on predicting and preventing pressure ulcers was published in May 1992, and the second, which focuses on treatment, was issued in December 1994. Synopses of the guidelines have been published in medical journals as well. (13-15) There are no data on the extent of the guidelines' readership or their influence on the clinical practice of primacy care physicians.

We conducted a survey of family physicians to determine their knowledge, altitudes, and practice preferences with regard to the prevention and treatment of pressure ulcers. In addition, we sought to assess the impact of the AHCPR guidelines on the physicians' knowledge and management of pressure ulcers.

METHOD

QUESTIONNAIRE

The 8-page, 34-question survey questionnaire consisted of four parts. Part 1 was designed to test the respondent's knowledge about pressure ulcers. Eleven multiple-choice questions had either single or multiple answers, constituting 43 scorable items. The items were based on the clinical practice guidelines from AHCPR. (13,15) The questions covered topics of general knowledge (staging, pathogenesis, and sites; 17 items), prevention (10 items), and treatment (16 items). Respondents were given a point for each correct answer, producing a possible score range of 0 to 43. Part 2 consisted of four questions focusing on (1) respondents' attitudes about adequacy of their training for managing pressure ulcers; (2) perceived effectiveness in treating pressure ulcers; (3) importance of pressure ulcers in primary care practice; and (4) the role of family physicians in managing pressure ulcers. Subjects rated their attitudes on a 4-point Likert-type scale. Part 3 of the questionnaire posed four hypothetical case histories, one each for an elderly patient with a stage 1 pressure ulcer, a stage 2 pressure ulcer, a stage 3 pressure ulcer, and multiple pressure ulcers (stage not revealed). To assess practice preferences, respondents were asked to indicate which given interventions they would order for each scenario. The remaining 15 items of the questionnaire collected information about each respondent's demographic characteristics, practice type, continuing medical education activity, clinical experience, training, and awareness of AHCPR guidelines.

SAMPLE

The survey was conducted in collaboration with Data Collection and Support Services, Division of Epidemiology, University of Minnesota School of Public Health. A pilot test was performed on a convenience sample of 30 family physicians in Wisconsin, following which minor revisions were made to the questionnaire.

The goal of the survey protocol was to obtain a 10% sample of the 1556 active members of the Minnesota Academy of Family Physicians (MAFP). The questionnaire was initially mailed to 304 randomly selected active MAFP members in December 1995. Twelve physicians were subsequently excluded for the following reasons: they were retired; were working as an emergency physician or a chronic pain rehabilitation physician; were working for an urgent care center, the state, or ml insurance company; or were out of the country. One week after the initial mailing, a reminder postcard was sent to nonrespondents, followed by another mailing of the questionnaire 4 weeks later. After the three mailings, 91 questionnaires had been returned. If a questionnaire had not been returned by 2 weeks after the third mailing, nonrespondents were contacted by telephone and politely asked to send in a completed questionnaire. Response was solicited until the target sample size (N=155) was achieved.

ANALYSIS

Univariate associations between selected variables were tested using the chi-square and one-way ANOVA statistics where appropriate. The independence of correlates of pressure ulcer knowledge was tested by multivariate regression of the knowledge score on variables that had been associated in the univariate analysis at the P < .05 level. Two-tailed tests were used and P < .05 was adopted for statistical significance. Analyses were performed with SPSS for Microsoft Windows Release 6.1. (16)