Commentary: Cabanna M et al. (1999). Why don’t physicians follow clinical practice guidelines? A framework for improvement

Abstract

AbstractDespite wide promulgation, clinical practice guidelines have had limited effect on changing physician behaviour. Little is known about the process and factors involved in changing physician practices in response to guidelines. The aim is to review barriers to physician adherence to clinical practice guidelines. We searched the MEDLINE, Educational Resources Information Center and Health STAR databases (January 1966 to January 1998), bibliographies; textbooks on health behaviour or public health and references supplied by experts to find English language article titles that describe barriers to guideline adherence. Of 5658 articles initially identified, we selected 76 published studies describing at least one barrier to adherence to clinical practice guidelines, practice parameters, clinical policies or national consensus statements. One investigator screened titles to identify candidate articles, then two investigators independently reviewed the texts to exclude articles that did not match the criteria. Differences were resolved by consensus with a third investigator. Two investigators organized barriers to adherence into a framework according to their effect on physician knowledge, attitudes or behaviour. This organization was validated by three additional investigators. 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 one type of barrier. Studies on improving physician guideline adherence may not be generalizable because 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 towards improving guideline adherence and a framework for future research. Abstract reprinted from the Journal of the American Medical Association volume 282, Cabanna M et al., ‘Why don’t physicians follow clinical practice guidelines? A framework for improvement.’, pages 1458–1465. © 1999, reproduced with permission from the American Medical Association.