Does changing physician behaviors alter physician attitudes? An exploration of innovation diffusion within a mandated situation

This study seeks to explain how the process of adopting payer-mandated, medical care guidelines differs from classical diffusion theory specifically in the areas of (a) information gathering techniques, including the use of active versus passive information, the type of information sought, and the sources of information used; (b) the use of re-invention that more closely aligns changes in behavior to the physician's perceived needs; (c) the development of cognitive dissonance and physician response to dissonance; and (d) the change of medical care norms, as evidenced by the expansion of mandated behavior into non-mandated areas. This qualitative case study is based on semi-structured interviews with 16 physician preferred-providers, hospital administrative staff from three hospitals, and four pediatricians, all involved with one HMO's mandated reduction in length of stay from 48 to 24 hours for women experiencing uncomplicated vaginal delivery.;Analysis of data has demonstrated that the process of adopting payer-mandated medical care guidelines differs from classical diffusion theory and that there is a potential for changing physician attitudes and norms by mandating behavior change. Specifically, (1) Physicians in a mandated change situation do not engage in a continuous active search for information. Further, the physicians' primary information source was the change agent. (2) Four of the 16 physicians interviewed gave "shading the truth" or "looking harder" for reasons to extend a patient's stay as examples of re-invention by gaming the system, and 2 other physicians were assessed to display partial compliance as examples of re-invention. (3) Thirteen of the 16 physicians were found to have experienced dissonance, 10 of whom responded by changing their attitude toward the shortened length of stay. (4) Of those 10 physicians experiencing total or partial attitude change, 8 expanded their application of the shortened length of stay to include non-mandated patients.;The results of this study suggest that corporate entities have been successful in changing physician practice patterns and reducing variation by connecting physician behavior to physician opportunity for revenue. Physician resistance to change appears to be diminished in the face of meaningful sanctions. Physicians in this study shifted away from their strict role as patient advocate when their behavior was directly tied to their revenue. Thus, the physician-patient relationship was altered from the ideal in the presence of mandated practice innovations tied to the physician's revenue. Overall, with mandated guidelines having been shown to change practice norms in this situation, this study supports the Institutes of Medicine's Committee on Clinical Practice Guidelines' recommendation for a national guideline assessment tool and certification body.