Why don't physicians follow clinical practice guidelines? A framework for improvement.

CONTEXT Despite wide promulgation, clinical practice guidelines have had limited effect on changing physician behavior. Little is known about the process and factors involved in changing physician practices in response to guidelines. OBJECTIVE To review barriers to physician adherence to clinical practice guidelines. DATA SOURCES We searched the MEDLINE, Educational Resources Information Center (ERIC), and HealthSTAR databases (January 1966 to January 1998); bibliographies; textbooks on health behavior or public health; and references supplied by experts to find English-language article titles that describe barriers to guideline adherence. STUDY SELECTION Of 5658 articles initially identified, we selected 76 published studies describing at least 1 barrier to adherence to clinical practice guidelines, practice parameters, clinical policies, or national consensus statements. One investigator screened titles to identify candidate articles, then 2 investigators independently reviewed the texts to exclude articles that did not match the criteria. Differences were resolved by consensus with a third investigator. DATA EXTRACTION Two investigators organized barriers to adherence into a framework according to their effect on physician knowledge, attitudes, or behavior. This organization was validated by 3 additional investigators. DATA SYNTHESIS The 76 articles included 120 different surveys investigating 293 potential barriers to physician guideline adherence, including awareness (n = 46), familiarity(n = 31), agreement (n = 33), self-efficacy (n = 19), outcome expectancy (n = 8), ability to overcome the inertia of previous practice (n = 14), and absence of external barriers to perform recommendations (n = 34). The majority of surveys (70 [58%] of 120) examined only 1 type of barrier. CONCLUSIONS Studies on improving physician guideline adherence may not be generalizable, since barriers in one setting may not be present in another. Our review offers a differential diagnosis for why physicians do not follow practice guidelines, as well as a rational approach toward improving guideline adherence and a framework for future research.

[1]  J. Stross,et al.  The dissemination of new medical information. , 1979, JAMA.

[2]  S. Whitbourne,et al.  How physicians view the process of change in their practice behavior. , 1982, Journal of medical education.

[3]  H. Wechsler,et al.  The physician's role in health promotion--a survey of primary-care practitioners. , 1983, The New England journal of medicine.

[4]  J. Prochaska,et al.  Stages and processes of self-change of smoking: toward an integrative model of change. , 1983, Journal of consulting and clinical psychology.

[5]  E F Cook,et al.  Screening procedures in the asymptomatic adult. Comparison of physicians' recommendations, patients' desires, published guidelines, and actual practice. , 1985, JAMA.

[6]  R H Brook,et al.  Persuasive communication and medical technology assessment. , 1985, Archives of internal medicine.

[7]  A. Bandura.  Social Foundations of Thought and Action: A Social Cognitive Theory , 1985 .

[8]  Survey of physicians‚ attitudes and practices in early cancer detection , 1985, CA: a cancer journal for clinicians.

[9]  D. Fleming,et al.  Haemophilus influenzae b polysaccharide vaccine. Physician acceptance and use of a new vaccine. , 1986, A M A Journal of Diseases of Children.

[10]  K. Wells,et al.  The practices of general and subspecialty internists in counseling about smoking and exercise. , 1986, American journal of public health.

[11]  Cancer screening and prevention. Knowledge, attitudes, and practices of New York City physicians. , 1987, New York state journal of medicine.

[12]  D. Kanouse,et al.  Effects of the National Institutes of Health Consensus Development Program on physician practice. , 1987, JAMA.

[13]  P. Remington,et al.  Are physicians advising smokers to quit? The patient's perspective. , 1987, JAMA.

[14]  M. Johnsson.  Evluation of The Consensus Conference Program in Sweden: its Impact on Physicians , 1988, International Journal of Technology Assessment in Health Care.

[15]  P. Whelton,et al.  Awareness, use, and impact of the 1984 Joint National Committee consensus report on high blood pressure. , 1988, American journal of public health.

[16]  C. Begg,et al.  Publication bias : a problem in interpreting medical data , 1988 .

[17]  D. Taylor,et al.  A randomized trial of a family physician intervention for smoking cessation. , 1988, JAMA.

[18]  G. Oster,et al.  The cost-effectiveness of counseling smokers to quit. , 1989, JAMA.

[19]  P. Hasselback,et al.  Attitudes and practices of primary care physicians in the management of elevated serum cholesterol levels. , 1989, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[20]  D. Kanouse.  Changing medical practice through technology assessment : an evaluation of the NIH Consensus Development Program , 1989 .

[21]  Obstacles to family practitioners' use of screening tests: determinants of practice? , 1989, Preventive medicine.

[22]  M. Enkin,et al.  Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians. , 1989, The New England journal of medicine.

[23]  C. Naylor,et al.  Coronary thrombolysis--clinical guidelines and public policy: results of an Ontario practitioner survey. , 1990, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[24]  M. Field,et al.  Medical practice guidelines: current activities and future directions. , 1990, Annals of internal medicine.

[25]  W. Kapoor,et al.  Health promotion and disease prevention in the elderly. Comparison of house staff and attending physician attitudes and practices. , 1990 .

[26]  Survey of Alabama Physicians' Use of Mammography, 1989 , 1990, Southern medical journal.

[27]  Survey of Alabama physicians' use of mammography, 1989. , 1990 .

[28]  M. Chassin,et al.  Practice guidelines: best hope for quality improvement in the 1990s. , 1990, Journal of occupational medicine. : official publication of the Industrial Medical Association.

[29]  B. Trock,et al.  Breast Screening Practices Among Primary Physicians: Reality And Potential , 1990, The Journal of the American Board of Family Medicine.

[30]  R. Grol.  National standard setting for quality of care in general practice: attitudes of general practitioners and response to a set of standards. , 1990, The British journal of general practice : the journal of the Royal College of General Practitioners.

[31]  M. Field,et al.  Clinical practice guidelines : directions for a new program , 1990 .

[32]  L. Goldman.  Changing physicians' behavior. The pot and the kettle. , 1990, The New England journal of medicine.

[33]  D. Gold,et al.  Breast Cancer Screening in Older Women: Practices and Barriers Reported by Primary Care Physicians , 1991, Journal of the American Geriatrics Society.

[34]  N. Santanello,et al.  Change in cholesterol awareness and action. Results from national physician and public surveys. , 1991, Archives of internal medicine.

[35]  M. Enkin,et al.  Obstetrical attitudes and practices before and after the Canadian Consensus Conference Statement on Cesarean Birth. , 1991, Social science & medicine.

[36]  A. Liberati,et al.  The Impact of Patient Management Guidelines on the Care of Breast, Colorectal, and Ovarian Cancer Patients in Italy , 1991, Medical care.

[37]  D. Langkamp,et al.  Primary care physicians' knowledge about diphtheria-tetanus-pertussis immunizations in preterm infants. , 1992, Pediatrics.

[38]  E. Maibach,et al.  Cholesterol treatment practices of primary care physicians. , 1992, Public health reports.

[39]  S. Flocke,et al.  Physician agreement with US Preventive Services Task Force recommendations. , 1992, The Journal of family practice.

[40]  Florida's response to the Physician's National Cholesterol Education Program. , 1992, The Journal of the Florida Medical Association.

[41]  J Lomas,et al.  Retailing research: increasing the role of evidence in clinical services for childbirth. , 1993, The Milbank quarterly.

[42]  David Haber,et al.  Guide to clinical preventive services: a challenge to physician resourcefulness , 1993 .

[43]  S. Clark,et al.  Family physician acceptance of universal hepatitis B immunization of infants. , 1993, The Journal of family practice.

[44]  S. Clark,et al.  Reactions of pediatricians to a new Centers for Disease Control recommendation for universal immunization of infants with hepatitis B vaccine. , 1993, Pediatrics.

[45]  S. Woolf.  Practice guidelines: a new reality in medicine. III. Impact on patient care. , 1993, Archives of internal medicine.

[46]  Evaluation of universal hepatitis B immunization practices of Illinois pediatricians. , 1994, Archives of pediatrics & adolescent medicine.

[47]  S. Clark,et al.  Universal hepatitis B immunization of infants: reactions of pediatricians and family physicians over time. , 1994, Pediatrics.

[48]  L. Solberg,et al.  Physician-delivered smoking cessation advice: issues identified during ethnographic interviews , 1994 .

[49]  J Lomas,et al.  Evaluating the Message: The Relationship Between Compliance Rate and the Subject of a Practice Guideline , 1994, Medical care.

[50]  Dissemination of information about the US Preventive Service Task Force guidelines. , 1994, Archives of family medicine.

[51]  H. Rubin,et al.  Internists' Attitudes about Clinical Practice Guidelines , 1994, Annals of Internal Medicine.

[52]  C. Mansfield,et al.  Attitudes and behaviors towards clinical guidelines: the clinicians' perspective. , 1995, Quality in health care : QHC.

[53]  B. B. Hudak,et al.  Infant sleep position: pediatricians' advice to parents. , 1995, Pediatrics.

[54]  K. Weiss,et al.  Pediatric asthma care in US emergency departments. Current practice in the context of the National Institutes of Health guidelines. , 1995, Archives of pediatrics & adolescent medicine.

[55]  Primary care HMO clinicians' opinions about clinical practice guidelines. , 1995, HMO practice.

[56]  M. A. van 't Hof,et al.  Nutrition guidance by primary-care physicians: perceived barriers and low involvement. , 1995, European journal of clinical nutrition.

[57]  Attitudes to the Association of Anaesthetists recommendations for standards of monitoring during anaesthesia and recovery , 1995, Anaesthesia.

[58]  C. Diclemente,et al.  Measuring physician readiness to change cancer screening: preliminary results. , 1995, American journal of preventive medicine.

[59]  B. Prendergast,et al.  Hepatitis B immunisation among invasive cardiologists: poor compliance with United Kingdom guidelines. , 1995, British heart journal.

[60]  W. Meadow,et al.  Pediatric critical care physicians' attitudes about guidelines for the use of ribavirin in critically ill children with respiratory syncytial virus pneumonia. , 1995, Critical care medicine.

[61]  R. Roetzheim,et al.  Physician‐Reported Determinants of Screening Mammography in Older Women: The Impact of Physician and Practice Characteristics , 1995, Journal of the American Geriatrics Society.

[62]  D. Chao.  Clinical guidelines in primary care: a survey of general practitioners' attitudes and behaviour. , 1995, The British journal of general practice : the journal of the Royal College of General Practitioners.

[63]  A. Siriwardena.  GUIDELINES IN PRIMARY CARE: AN INVESTIGATION OF GENERAL PRACTITIONERS' ATTITUDES AND BEHAVIOUR TOWARDS CLINICAL GUIDELINES , 1995 .

[64]  J. Price,et al.  Family physicians' views of the preventive services task force recommendations regarding nutritional counseling. , 1994, Archives of family medicine.

[65]  A. Schuchat,et al.  Barriers to prevention of perinatal group B streptococcal disease. , 1995, The Pediatric infectious disease journal.

[66]  R. Luckmann,et al.  Periodic health evaluation of adults: a survey of family physicians. , 1995, The Journal of family practice.

[67]  H. Wigder,et al.  ACEP chest pain policy: emergency physician awareness. , 1996, Annals of emergency medicine.

[68]  A. Liberati,et al.  Physicians' view of practice guidelines. A survey of Italian physicians. , 1996, Social science & medicine.

[69]  J. Newton,et al.  General practitioners and clinical guidelines: a survey of knowledge, use and beliefs. , 1996, The British journal of general practice : the journal of the Royal College of General Practitioners.

[70]  T. Cheng,et al.  Tuberculosis Testing: Physician Attitudes and Practice , 1996 .

[71]  M Cohen,et al.  Clinical practice guidelines. New-to-practice family physicians' attitudes. , 1996, Canadian family physician Medecin de famille canadien.

[72]  G G Koch,et al.  The awareness-to-adherence model of the steps to clinical guideline compliance. The case of pediatric vaccine recommendations. , 1996, Medical care.

[73]  C. Woodward,et al.  Preventive care and barriers to effective prevention. How do family physicians see it? , 1996, Canadian family physician Medecin de famille canadien.

[74]  R. Hayward.  Clinical practice guidelines on trial. , 1997, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[75]  T. R. Taylor,et al.  Physician policies on the use of preventive hormone therapy. , 1997, American journal of preventive medicine.

[76]  T. Lieu,et al.  Blood lead testing by pediatricians: practice, attitudes, and demographics. , 1997, American journal of public health.

[77]  A. Taylor-Vaisey,et al.  Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. , 1997, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[78]  L. Jackson,et al.  Family physicians managing tuberculosis. Qualitative study of overcoming barriers. , 1997, Canadian family physician Medecin de famille canadien.

[79]  Attitudes about clinical practice guidelines in a mixed model HMO: the influence of physician and organizational characteristics. , 1997, HMO practice.

[80]  Awareness of consensus preventive medicine practice guidelines among primary care physicians. , 1997, American journal of preventive medicine.

[81]  L. Solberg,et al.  How important are clinician and nurse attitudes to the delivery of clinical preventive services? , 1997, The Journal of family practice.

[82]  B. Blanksby,et al.  How can and do Australian doctors promote physical activity? , 1997, Preventive medicine.

[83]  R D Hardern,et al.  What do accident and emergency medical staff think of practice guidelines? , 1997, European journal of emergency medicine : official journal of the European Society for Emergency Medicine.

[84]  J. Pacala,et al.  Pressure ulcers in adults: family physicians' knowledge, attitudes, practice preferences, and awareness of AHCPR guidelines. , 1997, The Journal of family practice.

[85]  L. Y. Landesman,et al.  Centers for disease control and prevention lead guidelines: do pediatricians know them? , 1997, The Journal of pediatrics.

[86]  P. James,et al.  Family physicians' attitudes about and use of clinical practice guidelines. , 1997, The Journal of family practice.

[87]  D. Shye,et al.  Primary care physicians' use of lumbar spine imaging tests: effects of guidelines and practice pattern feedback. , 1997, Journal of general internal medicine.

[88]  J. Eisenberg,et al.  Changing physicians' practices. , 1993, Tobacco control.

[89]  AWARENESS OF CONSENSUS PREVENTIVE MEDICINE PRACTICE GUIDELINES AMONG PRIMARY CARE PHYSICIANS , 1997 .

[90]  J. Ward,et al.  Local impact of the NHMRC early breast cancer guidelines: where to from here? , 1997, The Medical journal of Australia.

[91]  J. van der Voort,et al.  The struggle to diagnose UTI in children under two in primary care. , 1997, Family practice.

[92]  R. Alston.  Guidelines and cardiac anaesthetists , 1997, Anaesthesia.

[93]  R S Hayward,et al.  Clinical practice guidelines in general practice: a national survey of recall, attitudes and impact , 1997, The Medical journal of Australia.

[94]  T. Lauritzen,et al.  Do general practitioners want guidelines? Attitudes toward a county-based and a national college-based approach. , 1997, Scandinavian journal of primary health care.

[95]  G H Guyatt,et al.  Canadian physicians' attitudes about and preferences regarding clinical practice guidelines. , 1997, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[96]  A. Kaluzny,et al.  Physicians' reactions to change in recommendations for mammography screening. , 1997, American journal of preventive medicine.

[97]  B. Crabtree,et al.  Current trends in tobacco prevention and cessation in Nebraska physicians' offices. , 1997, The Journal of family practice.

[98]  P. Szilagyi,et al.  Lead screening practices of pediatric residents. , 1998, Archives of pediatrics & adolescent medicine.

[99]  D. Christakis,et al.  Pediatricians' awareness of and attitudes about four clinical practice guidelines. , 1998, Pediatrics.

[100]  Management of acute gastroenteritis in children in Israel. , 1998, Pediatrics.

[101]  J. Froom,et al.  Clinical practice guidelines on depression: awareness, attitudes, and content knowledge among family physicians in New York. , 1998, Archives of family medicine.

[102]  M Wolff,et al.  US family physicians' experiences with practice guidelines. , 1998, Family medicine.

[103]  A. Dunsis.  Local impact of the NHMRC early breast cancer guidelines: where to from here? , 1998, The Medical journal of Australia.