Barriers between guidelines and improved patient care: An analysis of AHCPR's Unstable Angina Clinical Practice Guideline

Objectives. To describe common barriers that limit the effect of guidelines on patient care, with emphasis on recommendations for triage in the Agency for Health Care Policy and Research (AHCPR) Unstable Angina Clinical Pract ice Guideline. Data Sources. Previously reported results from a prospective clinical study of 10,785 patients presenting; to the emergency department (ED) with sympt oms suggestive of acute cardiac ischemia. Study Design. Design is an analysis of the AHCPR guideline with regard to r ecognized barriers in guideline implementation. Presentation of hypothetica l scenarios to ED physicians was used to determine interrater reliability i n applying the guideline to assess risk and to make triage decisions. Principal Findings. The AHCPR guideline's triage recommendations demonstrat e (1) poor interobserver reliability in interpretation by ED physicians; (2 ) limited applicability of recommendations for outpatient management (appli es to 6 percent of patients presenting to the ED with unstable angina); (3) incomplete specifications of exceptions that may require deviation from gu ideline recommendations; (4) unexpected effects on medical care by signific antly increasing the demand for limited intensive care beds; and (5) unknow n effects on patient outcomes. In addition, analysis of the guideline highl ights the need to address organizational barriers, such as administrative p olicies that conflict with guideline recommendations and the need to adapt the guideline to conform to local systems of care. Conclusions. Careful analysis of guideline attributes, projected effect on medical care, and organizational factors reveal several barriers to success ful guideline implementation that should be addressed in the design of futu re guideline-based interventions.