title: Reasons for intentional guideline non-adherence: A systematic review.
abstract: BACKGROUND
  Reasons for intentional non-adherence to guidelines are largely unknown. The objective of this systematic review was to gain insight into and categorize reasons for intentional non-adherence and their validity. Non-adherence might be a conscious choice by either the clinician or the patient, and is not influenced by external factors (e.g. lack of knowledge or resources). We use the term intentional non-adherence to describe this class of reasons for not following guideline recommendations.
  
  
  METHODS
  Two independent reviewers examined MEDLINE citations for studies that investigated reasons for guideline non-adherence. The obtained articles were assessed for relevance and quality. Our search yielded 2912 articles, of which 16 matched our inclusion criteria and quality requirements. We planned to determine an overall ranking of categories of non-adherence.
  
  
  RESULTS
  Seven studies investigated clinical reasons and performed adjudication, while nine studies did not perform adjudication. Non-adherence varied between 8.2% and 65.3%. Meta-analysis proved unfeasible due to heterogeneity of study methodologies. The percentage of reasons deemed valid by adjudication ranged from 6.6% to 93.6%. Guideline non-adherence was predominantly valid; contra-indications and patient preference were most often reported as reasons for intentional non-adherence.
  
  
  CONCLUSIONS
  We found a wide range of rates of non-adherence to clinical guidelines. This non-adherence is often supported by valid reasons, mainly related to contra-indications and patient preference. Therefore, we submit that many guideline deviations are intentional and these deviations do not necessarily impact quality of care.
authors.affiliation: Academic Medical Centre, Department of General Practice and department of Medical Informatics, Amsterdam, The Netherlands. Electronic address: d.l.arts@amc.nl.
authors.forename: Derk L
authors.initials: DL
authors.lastname: Arts
authors.affiliation: Academic Medical Centre, Department of General Practice, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
authors.forename: Albertine G
authors.initials: AG
authors.lastname: Voncken
authors.affiliation: Academic Medical Centre, Department of Medical Informatics, Amsterdam, The Netherlands.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Medlock
authors.affiliation: Academic Medical Centre, Department of Medical Informatics, Amsterdam, The Netherlands.
authors.forename: Ameen
authors.initials: A
authors.lastname: Abu-Hanna
authors.affiliation: Academic Medical Centre, Department of General Practice, Amsterdam, The Netherlands.
authors.forename: Henk C P M
authors.initials: HC
authors.lastname: van Weert
mesh_terms: D019983:Guideline Adherence / Q000592:standards* / Q000706:statistics & numerical data; D006282:Health Personnel / Q000523:psychology* / Q000592:standards*; D006801:Humans; D011787:Quality of Health Care / Q000592:standards*
keywords: Audit and feedback; Decision making; Guideline adherence; Healthcare quality improvement; Non-adherence; Practice guidelines