I was interested to see this paper on the limited success of implementation of clinical practice guidelines (with thanks to Irina Ibraghimova). The emphasis is on high-income countries. I would be interested to hear perspectives on implementation of clinical practice guidelines in low-income settings.
Hand Clin. 2014 Aug;30(3):361-365. doi: 10.1016/j.hcl.2014.04.007. Epub 2014 May 27. Clinical Practice Guidelines: What Are They and How Should They Be Disseminated? [restricted access] Graham B.
Abstract
Clinical practice guidelines summarize the available evidence for patient management in a format that is easy for clinicians to use. These guidelines usually use methodologically rigorous principles for retrieving and evaluating the literature and for establishing consensus among work group members, but implementation by clinicians is often incomplete. The reasons why guidelines fail to gain widespread acceptance vary with the topic and clinician group. Successful dissemination of practice guidelines requires an understanding of the barriers to implementation and the use of multiple strategies to address these. This article examines the factors affecting implementation and the approaches to overcoming these obstacles.
Key points
- Clinical practice guidelines use rigorous methods to find, evaluate, and summarize the literature into a series of points that should help guide clinicians in their management of patients.
- Clinicians are often reluctant to implement the recommendations of practice guidelines and the reasons for this vary with the topic and with the practice context.
- Multiple strategies to overcome the barriers preventing implementation should be used together and be selected from the particular characteristics of the target clinician population.
EXTRACTS (selected by Neil PW)
‘The evidence-based practice movement that started in the 1980s had at its foundation the idea that outcomes would improve if patients were managed using principles developed from medical knowledge accumulated from a body of methodologically sound clinical research. Clinical practice guidelines (CPGs) sought to summarize this medical evidence into general management pathways that clinicians could use to provide patients with the best care possible. However, despite this seemingly laudable objective, CPGs in general have had, in most instances, a modest impact on day-to-day practice. In some cases CPGs have been essentially ignored by most clinicians. The reasons for the failure of CPGs to influence practice are varied but, before examining these, it is important to understand how CPGs are developed (although these methods continue to evolve) and what they represent.’
‘Why do physicians not use CPGs?
- Implementation of CPGs by clinicians may be poorer than expected despite the methodologically rigorous process in the CPG development…
- Lack of Awareness…
- Lack of Familiarity…
- Lack of Agreement…
- Lack of Self-efficacy…
- Lack of Outcome Expectancy…
- Inertia of Previous Practice…
- External Barriers may include simple factors such as the time required to put into practice a particular recommendation. Guidelines may be perceived as difficult to implement or physicians may think that recommendations conflict with patient preferences. In addition, implementation of guidelines may also be affected by practice circumstances, such as facilities that are under the control of an institution, increased costs, decreased reimbursement, or the perception of an increased vulnerability to liability…’
How and why do physicians change their practices?
The ways that physicians change their behavior has been reviewed by Molding and colleagues.10 They identify 8 key principles that have an important impact on changing physician behavior and they conclude that these factors have to be taken into consideration in the dissemination of evidence-based CPGs:
- – Recognition that change in behavior is a process
- – Thought leaders (change agents) must identify with the concerns of clinicians who are the targets of CPGs
- – Assessment of the readiness to change and the specific barriers to these changes
- – The recognition that multiple strategies for change are more effective than any single strategy; education of clinicians must address the domains of knowledge, attitudes, and skill development; education strategies must encourage interaction and participation by clinicians
- – Social influences may play an important role
- – Environmental support (ie, support by institutions) is important to both initiating change and maintaining the new status quo
The investigators concluded that consideration of these factors should allow the development of effective dissemination strategies that address the specific barriers to change of the target clinician population… The reasons underlying the failure of physicians to adopt the recommendations contained in CPGs are varied and dictate a similarly varied and multidimensional approach to informing, reminding, and reinforcing clinician behavior.
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