Clinical practice guidelines, produced by various professional organizations and academic institutions, are usually considered the best practices for clinical care. But how do physicians use guidelines, and what factors influence their use?
During the last 25 years, clinical practice guidelines (CPGs) have become an accepted part of medical care. A CPG is an authoritative series of rules or suggestions for the treatment of a clinical disorder. Many contemporary CPGs are referred to as evidence-based guidelines, because they are created using objective research information. These guidelines, produced by various professional organizations and academic institutions, are usually considered the best practices or gold standards for clinical care. The increasing amount of time and energy devoted to developing CPGs and implementing them in clinical practice raises a number of important questions about how they are used by physicians and what factors influence their use.
Barriers to CPG use
Although CPGs are accepted standards of care, several studies suggest that they have not been as widely adopted by physicians as their developers might have hoped.1-3 Many clinicians accept the concept of CPGs but, for various reasons, don't effectively incorporate them into their practices. In a survey of 1878 Canadian physicians, only 52% reported that they used guidelines at least once a month, and more than 25% expressed concerns about the source of the guidelines, their rigidity, and the fear that physicians might lose their sense of professional autonomy if they followed the guidelines.4
Another survey of 34 general practitioners in England found several barriers to the use of accepted evidencebased hypertension treatment guidelines. 5 Some physicians did not think the data used for the guidelines applied to their patients. Others did not follow the guidelines because they thought they were outdated, they did not feel a sense of ownership toward the guidelines, or they simply didn't know about them. Still others claimed that the time and financial pressures they felt made the treatment of hypertension and the use of guidelines a low priority. Ironically, these seem to be the very practitioners who should have been using the guidelines.
Cabana and associates6 reviewed 76 articles that investigated barriers to physician use of CPGs. They found 293 barriers that they divided into 3 broad groups, based on physician knowledge (lack of awareness and familiarity with the guidelines), attitudes (resistance to changing prior patterns of practices, lack of agreement with specific guidelines, lack of agreement with guidelines in general, concerns about whether the guidelines would work, and concerns about whether the clinician would be able to implement the guidelines), and external factors (difficulty or complexity of the guidelines, inconvenience of guideline implementation, patient resistance, and lack of time, reminders, and resources). The authors noted that few studies examined the full variety of barriers that may affect the use of practice guidelines.
Veatch,7 commenting on the study, argued that physicians and patients might rationally disagree with the recommendations of a guideline if those recommendations did not represent their outcome value judgments. Suppose, he explained, a guideline stated that antibiotics and tympanostomy tubes should only be used for children with otitis media to prevent long-term damage. A child's physician and parents could rationally disagree with the CPG if they thought that shortterm relief was also an appropriate outcome of treatment.
Several other factors have also been reported to affect the adoption of CPGs in clinical practice including the quality of the guidelines, the characteristics of the clinician and practice setting, the role of incentives, regulation by official organizations, and patient demands and compliance.8
Problems with CPGs
Although there have been several investigations of the barriers to the implementation of CPGs, there have been far fewer studies on the quality of the guidelines themselves. Are some of the concerns that practitioners have about CPGs justified? Are there problems with the structure and quality of some guidelines that are independent of their implementation yet influence their adoption by clinicians?
Shaneyfelt and colleagues9 reviewed 279 CPGs published between 1985 and 1997, using a 25-item scale they developed to evaluate whether the guidelines followed accepted development standards proposed by major medical organizations. On average, the guidelines complied with only 43% (10.77/25) of the standards. The compliance was highest (greater than 60%) for standards related to the statement of the purpose and rationale of the guidelines, the identification of the health problems targeted, the citation of the evidence used, the benefits and harms of the health practices recommended, and the specificity and flexibility of the recommendations.
Compliance was lowest (less than 25%) for several important standards related to the identification and summary of evidence, including the specification of the methods used to identify, extract, grade, classify, and combine the scientific evidence. There was little discussion of the potential professional biases of the individuals who developed the guidelines. The authors noted a gradual but statistically significant improvement in overall compliance with the standards for the survey period from 1985 to 1997. This improvement, however, did not occur for standards related to the identification and summary of evidence.
Cook and Giacomini,10 commenting on the Shaneyfelt study, discussed the complexity of developing and implementing guidelines and determining their effectiveness. While acknowledging the shortcomings of some guidelines, they questioned whether the standards used in the study applied equally well to all guidelines. They argued that guidelines are developed for different purposes and are based on different types of information. They may, for example, focus on the cost of care, the treatment outcome of individual patients, or the provision of the most effective care to groups of patients. Some guidelines, therefore, may legitimately deviate from the standards.
In a review of the potential benefits, limitations, and harms of CPGs, Woolf and associates11 stated that CPGs have a great potential to improve the consistency and quality of patient care, but they noted that it was not yet clear whether guidelines actually accomplished this in daily practice. They argued that guidelines may be wrong for all patients or for individual patients with special needs and cited 3 reasons why this might be so. The scientific evidence for a recommendation is often "lacking, misleading, or misinterpreted," the recommendations may be affected by the developers' clinical and scientific biases, and economic, policy, or other needs may take the place of the patients' clinical needs as the main guideline priority.
These reports highlight the importance of further studies on both the process of creating effective CPGs and the impact that guidelines have on the outcome of care. Unfortunately, proving that a guideline does have a significant positive impact on patient outcome is one of the most difficult aspects of developing a CPG.12,13
Resolving the barriers
These and other studies demonstrate that there are still many questions about how to develop useful guidelines, how to introduce them into clinical practice, and how to measure their effectiveness. Several authors have examined the process and made useful suggestions about how to resolve these barriers.
CPGs are more likely to be accepted by physicians if they are endorsed by respected professional organizations and colleagues rather than companies and institutions that have a major investment in reducing the cost of care. CPG developers need to test various formats for the guidelines (eg, summaries of recommendations, algorithms, manuals of collected guidelines) before releasing them because physicians apparently prefer some formats over others.4
Mailings of CPGs and formal continuing medical education programs have been reported to be minimally effective in changing clinical practice, perhaps because they are too impersonal. This conclusion is supported by reports that some of the more effective methods of ensuring compliance with CPGs are those that involve guideline monitoring, feedback about compliance, and multiple interactions between experts and clinicians using the guidelines.3,5,8,14 It is worth noting, however, that the successful implementation of an effective CPG does not necessarily guarantee continued clinician compliance with the guideline. 15 This means that there must be some ongoing system that reinforces compliance with the CPG.
Not surprisingly, the clinical habits that physicians develop over years of practice are resistant to significant change without a generous amount of one-to-one contact with experts who are supportive and mentoring rather than critical. Unfortunately, this is a timeintensive and expensive process. Medicine must therefore develop innovative and effective, but less expensive methods of monitoring guideline adherence and providing reasonable feedback to practitioners.
One obvious method is to use modern information technologies such as online help desks and expert-led forums. The essential component appears to be ongoing feedback from another knowledgeable clinician. Another approach might be confidential online treatment databases, the use of which would enable physicians to immediately compare their treatment decisions with those of their peers.
It is not sufficient to merely disseminate CPGs. If we truly believe that they make a significant difference in the quality of care, we need to develop new methods of encouraging compliance with the guidelines.
Dr Fauman is the author of Negotiating Managed Care: A Manual for Clinicians and Study Guide to DSM-IV-TR, both published by American Psychiatric Publishing, Inc. He is adjunct clinical associate professor of psychiatry at the University of Michigan and medical director of Magellan Health Services of Michigan.
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