Why don't physicians follow clinical practice guidelines? A framework for improvement

Michael D. Cabana, Cynthia S. Rand, Neil R. Powe, Albert W. Wu, Modena H. Wilson, Paul André C. Abboud, Haya R. Rubin

Research output: Contribution to journalReview article

4488 Citations (Scopus)

Abstract

Context: Despite wide promulgation, clinical practice guidelines have had limited effect on changing physician behavior. Little is known about the process and factors involved in changing physician practices in response to guidelines. Objective: To review barriers to physician adherence to clinical practice guidelines. Data Sources: We searched the MEDLINE, Educational Resources Information Center (ERIC), and HealthSTAR databases (January 1966 to January 1998); bibliographies; textbooks on health behavior or public health; and references supplied by experts to find English-language article titles that describe barriers to guideline adherence. Study Selection: Of 5658 articles initially identified, we selected 76 published studies describing at least 1 barrier to adherence to clinical practice guidelines, practice parameters, clinical policies, or national consensus statements. One investigator screened titles to identify candidate articles, then 2 investigators independently reviewed the texts to exclude articles that did not match the criteria. Differences were resolved by consensus with a third investigator. Data Extraction: Two investigators organized barriers to adherence into a framework according to their effect on physician knowledge, attitudes, or behavior. This organization was validated by 3 additional investigators. Data Synthesis: The 76 articles included 120 different surveys investigating 293 potential barriers to physician guideline adherence, including awareness (n = 46), familiarity (n= 31), agreement (n = 33), self- efficacy (n = 19), outcome expectancy (n = 8), ability to overcome the inertia of previous practice (n = 14), and absence of external barriers to perform recommendations (n - 34). The majority of surveys (70 [58%] of 120) examined only 1 type of barrier. Conclusions: Studies on improving physician guideline adherence may not be generalizable, since barriers in one setting may not be present in another. Our review offers a differential diagnosis for why physicians do not follow practice guidelines, as well as a rational approach toward improving guideline adherence and a framework for future research.

Original languageEnglish (US)
Pages (from-to)1458-1465
Number of pages8
JournalJournal of the American Medical Association
Volume282
Issue number15
DOIs
StatePublished - Oct 20 1999
Externally publishedYes

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Practice Guidelines
Guideline Adherence
Physicians
Research Personnel
Consensus
Information Centers
Aptitude
Textbooks
Information Storage and Retrieval
Health Behavior
Bibliography
Self Efficacy
MEDLINE
Differential Diagnosis
Language
Public Health
Organizations
Databases
Guidelines

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Why don't physicians follow clinical practice guidelines? A framework for improvement. / Cabana, Michael D.; Rand, Cynthia S.; Powe, Neil R.; Wu, Albert W.; Wilson, Modena H.; Abboud, Paul André C.; Rubin, Haya R.

In: Journal of the American Medical Association, Vol. 282, No. 15, 20.10.1999, p. 1458-1465.

Research output: Contribution to journalReview article

Cabana, Michael D. ; Rand, Cynthia S. ; Powe, Neil R. ; Wu, Albert W. ; Wilson, Modena H. ; Abboud, Paul André C. ; Rubin, Haya R. / Why don't physicians follow clinical practice guidelines? A framework for improvement. In: Journal of the American Medical Association. 1999 ; Vol. 282, No. 15. pp. 1458-1465.
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