Why don't physicians follow clinical practice guidelines? A framework for improvement (April 1999)

Summary

The successful implementation of clinical practice guidelines should improve quality of care by decreasing inappropriate variation and expediting the application of effective advances to practice. However, despite wide promulgation, practice guidelines have had limited effect on changing physician behavior.

Cabana et al. conducted a systematic review of the barriers to physician adherence to clinical practice guidelines, practice parameters, clinical policies or national consensus statements.

They found that physician adherence is dependent on physician awareness (31 examples), agreement (68 examples), self-efficacy (13 examples), outcome expectancy (12 examples), motivation (3 examples), and the absence of external barriers to perform guideline recommendations (62 examples). The findings suggest that studies describing interventions to improve physician adherence may not be generalisable, since barriers in one setting may not be present in another.

Using this analysis, the authors propose a framework which describes the barriers that must be overcome to improve physician adherence. This framework can be used (1) as a method to profile barriers or sources of poor adherence and thus (2) as a diagnostic tool to standardise and select appropriate interventions to improve adherence. The selection of interventions to change physician behaviour has been haphazard in the past. This analysis offers a more rational approach towards improving physician adherence to practice guidelines as well as a framework for further research.