Why don't physicians adhere to guideline recommendations in practice? An analysis of barriers among Dutch general practitioners.
BACKGROUND
Despite wide distribution and promotion of clinical practice guidelines, adherence among Dutch general practitioners (GPs) is not optimal. To improve adherence to guidelines, an analysis of barriers to implementation is advocated. Because different recommendations within a guideline can have different barriers, in this study we focus on key recommendations rather than guidelines as a whole, and explore the barriers to implementation perceived by Dutch GPs.


METHODS
A qualitative study using six focus groups was conducted, in which 30 GPs participated, with an average of seven per session. Fifty-six key recommendations were derived from twelve national guidelines. In each focus group, barriers to the implementation of the key recommendations of two clinical practice guidelines were discussed. Focus group discussions were audiotaped and transcribed verbatim. Data was analysed by using an existing framework of barriers.


RESULTS
The barriers varied largely within guidelines, with each key recommendation having a unique pattern of barriers. The most perceived barriers were lack of agreement with the recommendations due to lack of applicability or lack of evidence (68% of key recommendations), environmental factors such as organisational constraints (52%), lack of knowledge regarding the guideline recommendations (46%), and guideline factors such as unclear or ambiguous guideline recommendations (43%).


CONCLUSIONS
Our study findings suggest a broad range of barriers. As the barriers largely differ within guidelines, tailored and barrier-driven implementation strategies focusing on key recommendations are needed to improve adherence in practice. In addition, guidelines should be more transparent concerning the underlying evidence and applicability, and further efforts are needed to address complex issues such as comorbidity in guidelines. Finally, it might be useful to include focus groups in continuing medical education as an innovative medium for guideline education and implementation.
Lugtenberg
Marjolein
M
Scientific Centre for Transformation in Care and Welfare (Tranzo), Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands. m.lugtenberg@uvt.nl
Zegers-van Schaick
Judith M
JM
Westert
Gert P
GP
Burgers
Jako S
JS
BMC Med Inform Decis Mak. 2008 Sep 12;8:38
18789150
J Eval Clin Pract. 2007 Dec;13(6):860-6
18070256
Qual Saf Health Care. 2007 Apr;16(2):143-9
17403764
Qual Saf Health Care. 2009 Oct;18(5):385-92
19812102
Cochrane Database Syst Rev. 2001;(2):CD003030
11406063
Qual Health Care. 1995 Mar;4(1):55-64
10142039
Lancet. 2003 Oct 11;362(9391):1225-30
14568747
Lancet. 1993 Nov 27;342(8883):1317-22
7901634
Spine (Phila Pa 1976). 2001 Aug 1;26(15):E348-53
11474367
Health Aff (Millwood). 2006 Nov-Dec;25(6):w555-71
17102164
BMC Health Serv Res. 2003 Mar 24;3(1):8
12659640
N Engl J Med. 2004 Dec 30;351(27):2870-4
15625341
Implement Sci. 2006 Aug 09;1:16
16899124
BMJ. 1999 Feb 27;318(7183):593-6
10037645
Arch Pediatr Adolesc Med. 2000 Jul;154(7):685-93
10891020
J Gen Intern Med. 2006 Feb;21 Suppl 2:S14-20
16637955
JAMA. 1999 Sep 1;282(9):867-74
10478694
J Fam Pract. 2004 Jul;53(7):556-61
15251095
BMJ. 1997 Aug 16;315(7105):418-21
9277610
Int J Qual Health Care. 2002 Dec;14(6):509-18
12515337
Fam Pract. 1992 Mar;9(1):85-91
1634034
JAMA. 2006 Apr 26;295(16):1935-40
16639053
Br J Gen Pract. 2007 Dec;57(545):971-8
18252073
JAMA. 2005 Aug 10;294(6):716-24
16091574
JAMA. 2009 Feb 25;301(8):868-9
19244197
JAMA. 2001 Nov 28;286(20):2578-85
11722272
BMJ. 1998 Aug 15;317(7156):465-8
9703533
J Health Serv Res Policy. 2008 Apr;13(2):79-84
18416912
CMAJ. 1997 Jun 15;156(12):1715-23
9220923
CMAJ. 1997 Aug 15;157(4):408-16
9275952
Fam Pract. 2001 Aug;18(4):359-63
11477041
JAMA. 1999 Oct 20;282(15):1458-65
10535437
BMJ. 2000 Jan 1;320(7226):50-2
10617534
BMC Fam Pract. 2005 May 02;6(1):18
15865624
Int J Qual Health Care. 2004 Jun;16(3):229-36
15150154
BMC Health Serv Res. 2006 Dec 04;6:155
17144921
Health Technol Assess. 2004 Feb;8(6):iii-iv, 1-72
14960256
BMJ. 1995 Jul 8;311(6997):109-12
7613363