Effect of a clinical practice guideline on physician compliance

Objectives. To evaluate the effect of a clinical practice guideline for cesarean section due to dystocia on physician compliance, pregnancy outcome, and cesarean delivery rates, and to identify factors associated with physician non-compliance. Design. A cross-sectional study. Setting. A university hospital, Southern Thailand. Study participants. All 719 medical records of women undergoing a cesarean section due to dystocia (failure to progress; cephalopelvic disproportion) before and after implementation of the guideline, from 1 January 1998 to 31 December 2000. Intervention. A clinical practice guideline for cesarean section due to dystocia was implemented on 1 June 1999. Main outcome measures. Physician compliance, pregnancy outcomes, and cesarean section rates. Multivariate logistic regression was used to identify factors associated with physician non-compliance. Independent variables consisted of maternal age, height, parity, type of service, and birthweight. Results. Physician compliance with the guideline was 89.2%. Maternal complications were less in the period after implementation of the guideline. Fetal outcomes were not different between the two periods. The cesarean section rates due to dystocia decreased after implementation of the guideline, from 10.7% in 1999 to 8.6% in 2002. Private practice, maternal short stature, and birthweight ≥3500 g were significant predictors of physician non-compliance. Conclusions. Physician compliance was high. A clinical practice guideline can reduce the cesarean section rates due to dystocia without increasing adverse outcomes. Physician non-compliance was more common in women with well known risk for cephalopelvic disproportion, and private practice.